A2124E: Route of Current Reconciled Medication List Transmission: Other Methods to Resident,Family,Caregiver, Step-by-Step

Step-by-Step Coding Guide for Item Set A2124E: Route of Current Reconciled Medication List Transmission: Other Methods to Resident/Family/Caregiver

1. Review of Medical Records

• Objective: To verify if the current reconciled medication list was transmitted to the resident, family, or caregiver using methods other than paper-based or electronic mail/email.
• Process:
  • Review care transition, discharge planning records, and communication logs to identify how the medication list was provided.
  • Check for notes in the resident’s file or in communication tools (e.g., patient portals, text messages) that might indicate alternative transmission methods.
  • Consult with staff members involved in the discharge or transition process, such as nurses or case managers, who might have facilitated the transmission.

2. Understanding Definitions

• Other Methods of Transmission: This includes any method of conveying the medication list that does not involve traditional paper-based or standard electronic means, such as verbal communication through phone calls, video calls, or other digital communication platforms that do not involve sending documents.

3. Coding Instructions

• Code A2124E:
  • 1: If the medication list was transmitted through other methods.
  • 0: If no other methods were used.
• Example: If the medication list was conveyed verbally over a phone call to a family member, code A2124E as '1'.

4. Coding Tips

• Confirm the specifics of the transmission method used and ensure it does not classify under traditional electronic or paper methods.
• Reassess to ensure the method used effectively communicates the necessary information accurately and securely.

5. Documentation

• Required Documentation:
  • Detailed entries in the resident's health records about the method and date of the medication list transmission.
  • Documentation of verbal confirmations or acknowledgments from the receiving party, noting their understanding and receipt of the information.
• Documentation should be comprehensive and provide clear evidence of the transmission method used.

6. Common Errors to Avoid

• Misclassifying standard electronic methods as 'other methods.'
• Insufficient documentation of the communication details, such as the date, time, and participant in the communication.
• Failing to document the receiver's acknowledgment of understanding the information received.

7. Practical Application

• Scenario: During the discharge process of a resident, the nurse coordinates with the resident’s daughter via a video call to discuss the resident's medication management plan. The nurse verbally goes through the medication list, explains each medication's purpose, dosage, and timing, and answers questions. The daughter confirms her understanding and notes down the information. This interaction is documented in the medical records, including the date, time, and summary of the discussion. Based on this documentation, A2124E is accurately coded as '1', indicating that the medication list was transmitted via an alternative communication method.

Please note that the information provided in this guide for MDS 3.0 Item set A2124E 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.