Understanding and Coding MDS 3.0 Item A2124C: Route of Current Reconciled Medication List Transmission (Verbal to Resident/Family/Caregiver)

Introduction

Purpose: Ensuring that residents and their caregivers have a clear understanding of their medication regimen at discharge is crucial for preventing medication errors. MDS Item A2124C focuses on whether the reconciled medication list was verbally communicated to the resident, their family, or caregiver. Proper coding of this item is essential to document that verbal instructions were provided, supporting the continuity of care and promoting resident safety.

What is MDS Item A2124C?

Explanation: MDS Item A2124C documents the method used to communicate the reconciled medication list to the resident, family, or caregiver at the time of discharge, specifically indicating if the information was transmitted verbally. This item is crucial in cases where a verbal explanation of medications, their purpose, and how to take them is necessary to ensure understanding, especially when the recipient may have limited literacy or when clarification is needed.

Guidelines for Coding A2124C

Coding Instructions:

1. Step 1: Confirm that the reconciled medication list was communicated verbally to the resident, family, or caregiver.

2. Step 2: Ensure that the verbal communication was clear, comprehensive, and that the recipient understood the instructions.

3. Step 3: Code '1' if the verbal transmission of the medication list occurred. Code '0' if this method of communication was not used.

   • Code 1: Indicates that the reconciled medication list was communicated verbally to the resident, family, or caregiver.
   • Code 0: Indicates that the verbal transmission did not occur.

Example Scenario: Mrs. Thompson is being discharged from the facility, and her daughter is her primary caregiver. The nurse provides a detailed verbal explanation of the reconciled medication list, explaining each medication, its purpose, and the correct administration. The daughter confirms her understanding and asks questions to clarify. In this case, MDS Item A2124C should be coded as '1'.

Best Practices for Accurate Coding

Documentation:

• Record the verbal communication of the medication list in the resident’s discharge summary, noting the details of the conversation, including any questions asked by the resident or caregiver.
• Include a statement confirming that the recipient demonstrated understanding of the information provided.

Communication:

• Engage the resident or caregiver in the discussion by asking them to repeat the instructions or explain how they will administer the medications. This technique, known as "teach-back," can help ensure they understand the instructions.
• Provide written materials to supplement the verbal instructions whenever possible.

Training:

• Train staff on effective communication strategies, especially for complex medication regimens, and on how to assess the recipient’s understanding.
• Conduct role-playing exercises to help staff practice delivering verbal instructions clearly and compassionately.

Conclusion

Summary: Accurate coding of MDS Item A2124C is essential for documenting that the reconciled medication list was communicated verbally, ensuring that residents and caregivers understand their medication regimen at discharge. This practice is a key component of safe and effective care transitions.

Reference

• Refer to CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, specifically Chapter 3, Page A-14, for detailed coding instructions on MDS Item A2124C.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item set MDS 3.0 Item A2124C: "Route of Current Reconciled Medication List Transmission (Verbal to Resident/Family/Caregiver)" 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.