A2124. Route of Current Reconciled Medication List Transmission to Resident

Item Rationale

This item collects important data to monitor how medication lists are transmitted at discharge.

Steps for Assessment

Identify all routes of transmission that were used to provide the resident’s current reconciled medication list to the resident, family member, significant other, guardian/legally authorized representative, and/or caregiver.

Coding Instructions

Please refer to the coding instructions for A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider.

Coding Tips for A2122 and A2124

The route of transmission usually is established with each subsequent provider, depending on how it is able to receive information from your facility. The route(s) may not always be documented in the resident’s record. It will be helpful to understand and document how your facility typically transmits information to each subsequent provider at discharge to prepare for coding this item.

More than one route of transmission may apply. Check all that apply.

Examples

A SNF is discharging and sending a resident to a hospital by ambulance. The driver obtains a printout and brings the resident’s medication list to the hospital. The facility follows up with a call to the subsequent provider and discusses the resident’s medications.

Coding: Check paper-based (D) and verbal (C) for A2122.

Rationale: Two routes for transmitting the medication list information were used—a paper copy of the list (D) and follow up verbal discussion (C). Both of these occurred at the time of discharge.

One of a SNF’s referral HHAs is preparing to admit a resident who will discharge soon. The HHA intake nurse has secure access to the SNF’s EHR to obtain important care planning information from the resident’s records, including the medication list.

Coding: Check Electronic Health Record (A) for A2122.

Rationale: The SNF provided access to the resident’s medication list through its EHR. Even if there is no confirmation that the intake nurse accessed the medication list from the SNF’s EHR system, code EHR (A) because it was made available by the SNF.

Resident P receives a paper copy of their medication list, receives education about their medications from the SNF nurse at discharge, and is notified that the SNF’s patient portal is another means by which they can obtain their discharge medication list.

Coding: Check Electronic Health Record (A), verbal (C), and paper-based (D) for A2124.

Rationale: The copy of the medication list is paper-based (D). The information about Resident P’s medication list was also communicated verbally by the nurse at the time of discharge (C). The resident portal uses the SNF’s EHR to provide access to the medication list (A). It is not necessary to confirm that Resident P is a registered user of and accessed the patient portal in order to code EHR (A) as a route.

A SNF participates in a regional HIE as does a local acute care hospital. When residents are discharged to this acute care hospital, the SNF’s discharge medication list is included in the medications section of a transfer summary document from its EHR, which is electronically exchanged through the HIE. The acute care hospital is then able to obtain and integrate the medication information into its EHR.

Coding: Check Electronic Health Record (A) and Health Information Exchange (B) for A2122.

Rationale: The medication information is exchanged by the regional HIE through health IT standards. Sending the medication information in transfer summary allows the acute care hospital to integrate the medication information into its EHR. Code as EHR (A), since it was used to generate and exchange the information, and as HIE (B), since it is the means through which information exchange is possible with external providers.

A SNF has developed an interface that allows documents from its EHR to be electronically faxed to the subsequent provider. The SNF’s EHR connects via a phone line to a designated receiver’s secure email at the subsequent provider.

Coding: Check paper-based (D) for A2122.

Rationale: Faxing information is considered paper-based as faxed documents are comparable to hard-copy documents and not computable.

A SNF generates the current reconciled medication list electronically from the medication administration record (MAR) and treatment administration record (TAR) and electronically sends via secure email to the subsequent provider.

Coding: Check Other Method (E) for A2122.

Rationale: Providing the medication list through secure email is considered “Other Method” for coding this item. The source of the medication list is not the EHR, and the list is not transmitted directly to the subsequent provider’s EHR, so do NOT check EHR (A).