A1300A: Medical record number, Step-by-Step

Step-by-Step Coding Guide for Item Set A1300A: Medical Record Number

1. Review of Medical Records

• Start by accessing the resident's file or electronic health record (EHR) system to locate the unique medical record number assigned to the resident upon admission or registration in the facility.

2. Understanding Definitions

• Medical Record Number: A unique identifier assigned to every resident’s medical record in a healthcare facility. This number is used to track and manage all clinical documentation, billing, and medical history associated with a resident.

3. Coding Instructions

• Enter the exact medical record number as found in the resident's chart or EHR. The number should be copied verbatim, including any letters, numbers, or symbols.

4. Coding Tips

• Double-check the number for accuracy before entering it into the MDS to avoid errors in resident identification.
• Use the exact format and case (upper or lower) as it appears in the medical records to maintain consistency.

5. Documentation

• Ensure that any use of the medical record number in documentation references the resident’s identity correctly and that privacy and confidentiality are maintained.
• Document the date when the number was verified and by whom, especially if discrepancies are noted or updates are made.

6. Common Errors to Avoid

• Misreading characters in the medical record number, especially confusing similar-looking numbers and letters (e.g., 0 and O, 1 and I).
• Failing to update the MDS if the medical record number changes due to system updates or errors in initial data entry.

7. Practical Application

• Example: A new resident, Mr. John Smith, is admitted to the facility. During his admission, he is assigned the medical record number "12345A". When completing the MDS for Mr. Smith, ensure that "12345A" is entered exactly as it appears in his admission paperwork and on his electronic health record.

Please note that the information provided in this guide for MDS 3.0 Item set  A1300A 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.