Step-by-Step Coding Guide for A2123: Provision of Current Reconciled Medication List to Resident at Discharge

Introduction

Ensuring residents receive a current reconciled medication list at discharge is crucial for maintaining medication safety and care continuity. This process aids in preventing adverse medication outcomes and supports effective care transitions.

Steps for Assessment

1. Determine Discharge Setting: Assess if the resident was discharged to a home setting or a setting not listed based on discharge location item A2105.
2. Medication List Provision: Confirm whether the facility provided the resident, family member, guardian/legally authorized representative, or caregiver with the current reconciled medication list at discharge.

Coding Instructions

• Code 0 (No): If the facility did not provide the current reconciled medication list at discharge to a home setting or a not listed location.
• Code 1 (Yes): If the facility provided the current reconciled medication list at discharge to a home setting or a not listed location.

Documentation Tips

• Ensure the provision of the medication list is documented in the resident's discharge summary.
• Utilize consumer-friendly terminology and plain language to enhance understanding.

Common Errors to Avoid

• Failing to provide the medication list in understandable language.
• Not documenting the provision of the medication list in the resident's medical record.

Practical Application

Make the provision of a current reconciled medication list a standard part of the discharge process to enhance medication safety and care coordination post-discharge.

The Step-by-Step Coding Guide for item A2123 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. Please note that 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.