Step-by-Step Coding Guide for Item Set A0500C: Resident Last Name

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s last name.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission forms, identification documents, and previous assessments.
  2. Identify Last Name: Look for the resident’s last name in all relevant documents.
  3. Confirm Details: Verify that the last name is consistently documented across all records.

2. Understanding Definitions

• Resident Last Name: The family name or surname of the resident. This is typically the name used for official and legal purposes.
• Key Points:
  • Legal Name: Ensure that the last name matches the resident’s legal name as documented in official records.
  • Consistency: The last name should be consistently recorded in all documents to avoid any discrepancies.

3. Coding Instructions

• Steps:
  1. Locate Last Name: Confirm the resident’s last name from the medical records and official identification documents.
  2. Verify Spelling: Ensure the last name is spelled correctly and matches the name on legal documents.
  3. Enter Last Name: Code A0500C with the exact last name of the resident, ensuring proper capitalization and spelling.

4. Coding Tips

• Accurate Identification: Double-check the spelling of the last name against legal documents to ensure accuracy.
• Consistent Terminology: Use consistent formatting and capitalization when documenting and coding the last name.
• Consult Records: If there is any uncertainty, consult with administrative staff or legal documents to verify the correct last name.

5. Documentation

• Required:
  • Admission Forms: Ensure the resident’s last name is accurately recorded in the admission forms.
  • Identification Documents: Include copies of legal identification documents (e.g., ID card, passport) that show the resident’s last name.
  • Assessment Records: Document the last name accurately in all assessment records.

6. Common Errors to Avoid

• Misspelling: Ensure the last name is spelled correctly and matches the legal documents.
• Inconsistent Documentation: Make sure the last name is consistently documented across all records.
• Assumptions: Do not assume the last name without verifying it from legal documents.

7. Practical Application

• Example:
  • Resident Profile: Jane Doe, an 80-year-old resident, is being admitted to the facility.
  • Steps:
    1. Review Records: The nurse reviews Jane’s admission forms and her legal ID, confirming her last name as “Doe.”
    2. Verify Spelling: The nurse ensures the last name is spelled correctly as “Doe” in all documents.
    3. Document and Code: The nurse enters “Doe” for item set A0500C, ensuring the correct spelling and capitalization.
  • Outcome: Jane’s last name is accurately documented and coded, ensuring consistency across all records.

Please note that the information provided in this guide for MDS 3.0 Item set A0500C was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.