A2124A: Route of Current Reconciled Medication List Transmission: EHR to Resident/Family/Caregiver, Step-by-Step
Step-by-Step Coding Guide for Item Set A2124A: Route of Current Reconciled Medication List Transmission: EHR to Resident/Family/Caregiver
1. Review of Medical Records
- Objective: Ensure accurate and complete transmission of the resident’s reconciled medication list.
- Steps:
- Access Records: Retrieve the resident's electronic health records (EHR).
- Verify Transmission: Confirm that the reconciled medication list has been transmitted to the resident, family, or caregiver via EHR.
- Cross-Check: Compare the transmitted list with the current medication orders to ensure accuracy.
2. Understanding Definitions
- Reconciled Medication List: A comprehensive list of all medications a resident is currently taking, including dosages and administration schedules, which is reviewed and updated to avoid medication errors.
- EHR Transmission: The process of electronically sending the reconciled medication list to the resident, family, or caregiver through the electronic health record system.
3. Coding Instructions
- Steps:
- Locate Item Set: Find item set A2124A on the MDS form.
- Assess Transmission Method: Confirm that the reconciled medication list was transmitted via EHR.
- Code the Item:
- 0: No, if the reconciled medication list was not transmitted via EHR to the resident/family/caregiver.
- 1: Yes, if the reconciled medication list was transmitted via EHR to the resident/family/caregiver.
- Complete Entry: Enter the appropriate code in the designated field for item set A2124A.
4. Coding Tips
- Ensure Accuracy: Double-check that the reconciled medication list transmitted via EHR matches the current medication orders.
- Consistent Documentation: Maintain consistent documentation of all transmissions of the reconciled medication list in the resident’s EHR.
- Engage with the Care Team: Work closely with the care team to verify the transmission process and ensure that all parties are informed.
5. Documentation
- Required:
- EHR Records: Documentation of the reconciled medication list transmitted via EHR.
- Transmission Logs: Records or logs indicating the date and time of the EHR transmission.
- Acknowledgement: Any acknowledgement or confirmation from the resident, family, or caregiver that they received the medication list.
- MDS Form: Correctly completed entry for item set A2124A, reflecting the EHR transmission status.
6. Common Errors to Avoid
- Inaccurate Coding: Avoid coding errors by ensuring that the reconciled medication list was indeed transmitted via EHR.
- Lack of Documentation: Ensure all transmissions are well-documented in the EHR and are accessible for verification.
- Assumptions: Do not assume the transmission was successful without proper confirmation or documentation.
7. Practical Application
- Example:
- Resident Background: Mr. John Smith’s reconciled medication list needs to be transmitted to his family caregiver via EHR.
- Review Process: Access Mr. Smith’s EHR, verify the reconciled medication list, and ensure it matches the current medication orders.
- Transmission: Confirm that the medication list was transmitted to Mr. Smith’s family caregiver through the EHR system.
- Coding Process:
- Step 1: Locate item set A2124A on the MDS form.
- Step 2: Verify the EHR transmission of the reconciled medication list.
- Step 3: Enter the appropriate code (e.g., “1” if the list was transmitted via EHR) in the designated field.
- Step 4: Document the process and ensure consistency with EHR records.
- Illustration:
- Provide a sample MDS form showing item set A2124A with the appropriate code entered, accompanied by screenshots or logs from the EHR system confirming the transmission.
Please note that the information provided in this guide for MDS 3.0 Item set A2124A 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.
