A1805: Entered From, Step-by-Step

Step-by-Step Coding Guide for Item Set A1805: Entered From

1. Review of Medical Records

• Objective: To accurately identify the type of setting or location from which the resident was admitted into the long-term care facility.
• Process:
  • Review admission documents and transfer forms for information on the resident’s prior location.
  • Check the initial intake and assessment forms completed upon the resident's arrival for any reference to the previous setting.
  • Consult with the admissions team or social services for additional details or clarifications about the resident's transfer.

2. Understanding Definitions

• Entered From: Refers to the specific setting or location from which the resident was transferred or admitted. Common examples include another nursing home, a hospital (acute or psychiatric), the community (including home), assisted living, or another health care facility.

3. Coding Instructions

• Code A1805:
  • Record the specific type of location as per predefined categories such as:
    • Hospital acute care
    • Hospital psychiatric
    • Another nursing home or swing bed
    • Home
    • Assisted living
    • Other
• Example: If a resident was transferred from an acute care hospital, document this in A1805 as ‘Hospital acute care’.

4. Coding Tips

• Verify the correct category by cross-referencing with discharge paperwork from the previous facility.
• Be precise in distinguishing between similar types of settings, such as acute care vs. psychiatric hospitals.

5. Documentation

• Required Documentation:
  • Admission record that clearly states the previous location.
  • Transfer documentation or referral notes specifying the setting from which the resident was admitted.
• Documentation should be complete and clearly support the coded entry to ensure accuracy and compliance.

6. Common Errors to Avoid

• Misidentifying the type of facility due to similar names or services (e.g., mistaking a residential health care facility for an assisted living facility).
• Relying on verbal reports without confirmation from official documents.
• Failing to update the MDS if initial information about the resident's previous location is corrected after further verification.

7. Practical Application

• Scenario: A resident is admitted to the facility from a local hospital after recovering from surgery. The admissions clerk reviews the hospital discharge summary which clearly notes that the resident is being transferred from the hospital’s acute care unit. This information is entered into the facility’s electronic health record system and correctly coded in A1805 as ‘Hospital acute care’. The MDS coordinator verifies this entry against the hospital documentation to ensure its accuracy before finalizing the MDS.

Please note that the information provided in this guide for MDS 3.0 Item set A1805 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.