Understanding and Coding MDS 3.0 Item A2122C: Route of Current Reconciled Medication List Transmission: Verbal to Provider
Understanding and Coding MDS 3.0 Item A2122C: Route of Current Reconciled Medication List Transmission: Verbal to Provider
Introduction
Purpose:
MDS Item A2122C, "Route of Current Reconciled Medication List Transmission: Verbal to Provider," is designed to document whether the resident’s reconciled medication list was transmitted verbally to the provider. This item is critical for ensuring that accurate and complete medication information is communicated during transitions of care, particularly when electronic or written transmission methods are not utilized.
What is MDS Item A2122C?
Explanation:
MDS Item A2122C is part of Section A, which gathers identification and demographic information for residents. This specific item focuses on whether the reconciled medication list was verbally communicated to the next healthcare provider. Verbal communication can occur in various scenarios, such as when providers are contacted by phone or in person to ensure immediate and direct exchange of medication information.
Accurate coding of this item helps ensure that the transition of care is smooth, and that all parties involved are aware of the resident's current medication regimen, thereby reducing the risk of medication errors.
Guidelines for Coding A2122C
Coding Instructions:
When coding MDS Item A2122C, use the following instructions based on the latest MDS 3.0 User’s Manual:
- Code 0: If the reconciled medication list was not transmitted verbally to the provider.
- Code 1: If the reconciled medication list was transmitted verbally to the provider.
- Code 9: If it is unknown whether the reconciled medication list was transmitted verbally to the provider.
The decision should be based on documented evidence within the resident’s medical records, including any notes or confirmations of verbal communication with the provider.
Example Scenario: A resident is being discharged from a skilled nursing facility to their primary care provider's office. Due to the urgent nature of the discharge, the nurse verbally communicates the resident's reconciled medication list to the provider over the phone. In this scenario, A2122C should be coded as 1.
Best Practices for Accurate Coding
Documentation:
Ensure that all verbal communications are thoroughly documented in the resident's medical record. This should include the date and time of the communication, the name of the provider receiving the information, and any relevant details discussed during the conversation.
Communication:
Given the potential for errors in verbal communication, it is essential that the person transmitting the medication information confirms that the receiving provider has understood the details accurately. Consider using a read-back process where the provider repeats the medication list back to confirm accuracy.
Training:
Staff should be trained on the importance of accurately documenting verbal transmissions of medication lists and on strategies to minimize errors during these communications. Regular refreshers on communication protocols can help maintain high standards of care.
Conclusion
Summary:
MDS Item A2122C plays a vital role in ensuring that the resident’s medication information is accurately transmitted verbally to the next provider during care transitions. By following the coding guidelines and maintaining detailed documentation, healthcare providers can help ensure continuity of care and reduce the likelihood of medication errors.
Click here to see a detailed Step-by-Step on how to complete this item set.
Reference
Please refer to the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page 2-22 for the specific guidelines and instructions related to this item.
Disclaimer
Please note that the information provided in this guide for MDS 3.0 Item A2122C was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.
