A1300C. Name by which resident prefers to be addressed, Step-by-Step

Step-by-Step Coding Guide for Item Set A1300C: Name by Which Resident Prefers to Be Addressed

This guide aims to facilitate accurate coding and documentation of the name a resident prefers to be addressed by in the MDS 3.0, specifically within item A1300C.

1. Review of Medical Records

• Objective: Determine the resident's preferred name.
• Key Points:
  • Review the resident's admission paperwork, interviews, and any personal preferences documentation for mentions of a preferred name.
  • Consult with the resident directly or with family members/caregivers if the preferred name is not clearly documented.

2. Understanding Definitions

• Objective: Clarify what is meant by "Preferred Name."
• Key Points:
  • Preferred Name: The name that the resident wishes to be called, which may differ from their legal name. This can include nicknames, shortened names, or any name that the resident identifies with and prefers.

3. Coding Instructions

• Objective: Guide on how to accurately document the resident's preferred name.
• Key Points:
  • Code the resident’s preferred name exactly as they have indicated, including any special spellings or capitalizations.
  • If the resident prefers to be called by their legal name, document this name in the item.

4. Coding Tips

• Ensure spelling accuracy by verifying the preferred name with the resident or their family/caregiver.
• Be respectful and sensitive to the resident's wishes, especially if their preferred name reflects their identity, cultural background, or personal history.

5. Documentation

• Objective: Maintain thorough documentation regarding the resident’s name preference.
• Key Points:
  • Document the process of determining the resident’s preferred name, including conversations with the resident or family and where the preference was first recorded.
  • Include the preferred name in care plans, medication administration records, and other relevant documentation to ensure consistent use across all staff.

6. Common Errors to Avoid

• Failing to update the resident’s preferred name in all relevant documentation if it changes or if the initial documentation was incorrect.
• Overlooking the importance of using the preferred name, which can impact the resident’s sense of identity and well-being.

7. Practical Application

• Scenario: Mrs. Elizabeth Johnson, a new resident, indicates during her admission interview that she prefers to be called "Betty." The RN Coordinator documents "Betty" as her preferred name in A1300C of her MDS assessment and communicates this preference during the next staff meeting. Subsequently, all facility staff address her as "Betty," and her preferred name is consistently used in all care documentation and interactions, reinforcing a personalized and respectful care environment.

The Step-by-Step Coding Guide for item A1300C 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.