A2123: Provision of Current Reconciled Medication List (To Resident), Step-by-Step
Step-by-Step Coding Guide for Item Set A2123: Provision of Current Reconciled Medication List (To Resident)
1. Review of Medical Records
- Objective: To ensure the provision of an accurate and reconciled medication list to the resident.
- Steps:
- Collect Information: Review the resident's medical records, including medication administration records (MARs), physician orders, and discharge summaries.
- Identify Medications: List all current medications prescribed to the resident, including dosages, routes, and frequencies.
- Confirm Reconciliation: Ensure that the medication list has been reconciled, resolving any discrepancies between what was ordered, what was prescribed, and what was administered.
2. Understanding Definitions
- Reconciled Medication List: A complete and accurate list of all medications a resident is currently taking, which has been reviewed and updated to resolve any discrepancies.
- Provision to Resident: Ensuring that the resident receives a copy of the current reconciled medication list before discharge or at the time of a significant change in care.
3. Coding Instructions
- Steps:
- Confirm Provision: Verify that a reconciled medication list has been provided to the resident.
- Document Evidence: Ensure there is documentation confirming the provision of the medication list to the resident.
- Code Appropriately: Code A2123 as "1" if the reconciled medication list was provided to the resident, and "0" if it was not.
4. Coding Tips
- Accurate Reconciliation: Ensure the medication list is thoroughly reconciled before providing it to the resident.
- Clear Communication: Explain the medication list to the resident, ensuring they understand their medications, dosages, and administration instructions.
- Consult Pharmacist: If there are any uncertainties or discrepancies, consult with a pharmacist for clarification.
5. Documentation
- Required:
- Medication List: Include a copy of the current reconciled medication list in the resident’s records.
- Proof of Provision: Document that the medication list was provided to the resident, including the date and time.
- Resident Acknowledgment: Obtain and document the resident’s acknowledgment of receipt of the medication list.
6. Common Errors to Avoid
- Incomplete Reconciliation: Ensure all discrepancies are resolved before finalizing the medication list.
- Lack of Documentation: Always document the provision of the medication list to the resident.
- Assumptions: Do not assume the resident understands the medication list without verifying and explaining it.
7. Practical Application
- Example:
- Resident Profile: Sarah, a 78-year-old resident, is being discharged from the facility.
- Steps:
- Review Records: The nurse reviews Sarah’s MARs, physician orders, and discharge summary to compile a list of current medications.
- Reconcile List: The nurse reconciles the medication list, resolving any discrepancies.
- Provide and Explain: The nurse provides Sarah with the reconciled medication list, explaining each medication, its dosage, and administration instructions.
- Document: The nurse documents the provision of the medication list in Sarah’s records and obtains her acknowledgment.
- Outcome: Sarah’s provision of the reconciled medication list is accurately documented and coded, ensuring continuity of care.
Please note that the information provided in this guide for MDS 3.0 Item set A2123 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.
