Step-by-Step Coding Guide for N2001: Drug Regimen Review

1. Review of Medical Records

Begin by thoroughly reviewing the resident’s medical records, focusing on medication orders, physician notes, pharmacy reports, and any recorded medication-related problems. Pay special attention to the 7-day look-back period preceding the ARD (Assessment Reference Date).

2. Understanding Definitions

• Drug Regimen Review (DRR): An interdisciplinary process to assess the medication regimen of a resident, looking for any irregularities, unnecessary drugs, or potential adverse effects.
• Irregularity Identified During Review: Includes any potential or actual issues related to the resident's medication regimen identified by nursing staff or through pharmacy review.

3. Coding Instructions

• Code 0 (No): If no medication irregularities were identified during the review.
• Code 1 (Yes): If any irregularity was identified. This includes irregularities found by nursing staff or reported by the pharmacy that required physician or pharmacist contact after the initial review.

4. Coding Tips

• Utilize interdisciplinary team insights, including input from pharmacists, nurses, and physicians.
• Consider all sources of information, including recent hospital records if the resident was hospitalized before the assessment period.
• Keep abreast of the most recent clinical guidelines and recommendations for medication management in the elderly.

5. Documentation

Document the review process, noting the date, time, and personnel involved. Clearly record any irregularities identified, actions taken, and outcomes. If irregularities are found, document communications with physicians or pharmacists, including recommendations and any changes made to the medication regimen.

6. Common Errors to Avoid

• Overlooking medications that were temporarily stopped but are part of the resident's regimen.
• Failing to document the resolution or follow-up of identified irregularities.
• Not involving the interdisciplinary team in the review process.

7. Practical Application

Example Scenario: Mrs. Smith, a resident, is on multiple medications for hypertension, diabetes, and chronic pain. During the DRR, the nursing staff notes that Mrs. Smith has been experiencing dizziness, which could be related to her blood pressure medications. They consult with the pharmacy, and an irregularity is identified related to a potential interaction between her medications. The physician is contacted, adjustments are made to her medication regimen, and the changes are documented in her medical records.

The Step-by-Step Coding Guide for item N2001 in MDS 3.0 Section N is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.