A2124C: Route of Current Reconciled Medication List Transmission: Verbal to Resident/Family/Caregiver, Step-by-Step
Step-by-Step Coding Guide for Item Set A2124C: Route of Current Reconciled Medication List Transmission: Verbal to Resident/Family/Caregiver
1. Review of Medical Records
The first step in coding for item A2124C involves a thorough review of the resident’s medical records. This includes:
- Physician’s Notes: Examine progress notes, history, and physical examination records for any mention of medication reconciliation and communication.
- Nursing Notes: Check nursing notes for observations and documentation of discussions with the resident, family, or caregivers about medication lists.
- Pharmacy Records: Review records from the pharmacy, especially regarding medication reconciliation and discharge instructions.
- Discharge Summaries and Transfer Documents: Look for any information related to the provision and explanation of the reconciled medication list at discharge.
- Interdisciplinary Notes: Check notes from all members of the care team, including social workers and therapists, for any documentation of verbal communication of the medication list.
2. Understanding Definitions
Understanding the key definitions related to this item is crucial:
- Route of Current Reconciled Medication List Transmission: This refers to the method by which the reconciled medication list is communicated to the resident, family, or caregiver at the time of discharge.
- Verbal Transmission: This includes any oral communication methods, such as in-person discussions, telephone calls, or video conferencing, where the reconciled medication list is verbally explained to the resident, family, or caregiver.
3. Coding Instructions
Follow these steps for accurate coding:
- Identify Verbal Transmission: Confirm that the current reconciled medication list was communicated verbally to the resident, family member, or caregiver.
- Document Verbal Communication: Ensure that this verbal communication is documented in the medical records.
- Select the Appropriate Code: For item A2124C, if verbal transmission was used, select:
- Code 1 (Yes): If the medication list was verbally communicated to the resident, family, or caregiver.
- Code 0 (No): If the medication list was not verbally communicated.
4. Coding Tips
- Detailed Documentation: Ensure that the verbal communication of the medication list is clearly documented in the medical record, including the date and the individual to whom the information was communicated.
- Multiple Routes: Remember that more than one route of transmission may apply. If the medication list was also provided in another format (e.g., paper-based, electronic), ensure all applicable routes are coded.
- Consistency: Ensure that the documented route of transmission matches the coding on the MDS form.
5. Documentation
Accurate documentation is critical for compliance and effective care planning:
- Daily Records: Maintain thorough daily records of all communications with the resident, family, or caregiver, especially related to medication management.
- Care Plans: Update care plans to reflect the provision and explanation of the reconciled medication list at discharge.
- Interdisciplinary Communication: Ensure all team members are informed of and document any verbal communication of the medication list and its impact on the resident’s care.
6. Common Errors to Avoid
- Inconsistent Documentation: Avoid discrepancies between the documented communication and the coding on the MDS form.
- Lack of Documentation: Ensure that all verbal communications regarding the medication list are thoroughly documented.
- Incorrect Coding: Double-check coding entries for accuracy, especially regarding the route of transmission used.
7. Practical Application
Use case studies and scenarios to apply your knowledge:
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Example 1: A resident is discharged, and the nurse verbally explains the reconciled medication list to the resident and their caregiver, detailing each medication and its purpose.
- Coding: A2124C would be coded 1 (Yes) for verbal transmission.
- Rationale: The nurse provided a verbal explanation of the medication list to both the resident and the caregiver.
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Example 2: A resident is discharged, and the reconciled medication list is sent via email, with no verbal explanation provided.
- Coding: A2124C would be coded 0 (No) for verbal transmission.
- Rationale: The communication of the medication list was done electronically, without a verbal explanation.
Please note that the information provided in this guide for MDS 3.0 Item set A2124C 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.
