Step-by-Step Coding Guide for Item Set A1300A: Medical Record Number

This guide facilitates accurate coding and documentation of a resident's Medical Record Number in the MDS 3.0, specifically within item A1300A.

1. Review of Medical Records

• Objective: To identify the resident's Medical Record Number.
• Key Points:
  • Examine the resident’s admission documents, billing information, and the cover or header of medical records to locate the Medical Record Number.
  • This number is often assigned at admission and used to track the resident’s medical documentation throughout their stay.

2. Understanding Definitions

• Objective: Clarify what the "Medical Record Number" is.
• Key Points:
  • Medical Record Number: A unique identifier assigned to each resident's medical file, facilitating efficient retrieval and management of their health information.

3. Coding Instructions

• Objective: Provide guidance on accurately entering the Medical Record Number.
• Key Points:
  • Enter the exact number as found in the resident's medical records without any alterations.
  • The number should be entered as a continuous sequence of digits or characters without spaces.

4. Coding Tips

• Ensure legibility and accuracy when transcribing the Medical Record Number to prevent errors in resident identification.
• Double-check the number for transcription errors, especially if the medical records use a combination of letters and numbers.

5. Documentation

• Objective: Ensure the Medical Record Number is consistently documented.
• Key Points:
  • The Medical Record Number should be prominently displayed on all pages of the resident’s medical records and any related documents.
  • Document any changes or corrections to the Medical Record Number in a log or notes section, including the reason for the change and the date it occurred.

6. Common Errors to Avoid

• Misreading or incorrectly transcribing the Medical Record Number, leading to potential confusion or misidentification.
• Confusing the Medical Record Number with other identifiers, such as Social Security Numbers or insurance policy numbers.

7. Practical Application

• Scenario: While completing the MDS for Mrs. Elaine Thompson, the RN Coordinator refers to her admission paperwork and recent lab reports to verify her Medical Record Number, 567890123. The coordinator ensures this number matches across all documentation and then accurately codes it into item A1300A of the MDS. This meticulous approach guarantees consistent resident identification and facilitates accurate medical record-keeping.

The Step-by-Step Coding Guide for item A1300A in MDS 3.0 Section A is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.