Step-by-Step Coding Guide for N2003. Medication Follow-up

1. Review of Medical Records:

Start by thoroughly reviewing the resident's medical records, including physician's orders, nursing notes, and medication administration records (MARs) for any medication changes due to a problem identified during the look-back period. This review helps to identify any recent medication issues and the steps taken to address them.

2. Understanding Definitions:

• Medication Change: Any addition, discontinuation, or dosage adjustment of a medication.
• Medication Follow-Up: The actions taken by healthcare providers in response to medication-related problems, which may include consultation with a physician or pharmacist, laboratory tests, monitoring for effectiveness and side effects, and adjusting the medication regimen as necessary.

3. Coding Instructions:

• Code 0, No: If there were no medication changes in the last 14 days OR there were changes but no follow-up was conducted by the end of the next day following the change.
• Code 1, Yes: If there was a medication change in the last 14 days AND follow-up was conducted by the end of the next day following the change.

4. Coding Tips:

• Ensure the follow-up action relates directly to the medication change.
• Follow-up can be carried out by any healthcare provider as part of the interdisciplinary team.
• Consultation with a pharmacist for medication review can be considered a follow-up action.

5. Documentation:

Document the specific medication change, the reason for the change, the follow-up action taken, and the outcome of the follow-up. This information should be clearly noted in the resident's medical records.

6. Common Errors to Avoid:

• Failing to recognize all types of medication changes, including temporary stops.
• Overlooking follow-up actions that may not involve changes to medication but include monitoring and consultation.
• Not documenting follow-up actions or outcomes in the resident's medical records.

7. Practical Application:

Example Scenario: A resident's antihypertensive medication dosage is increased due to elevated blood pressure readings. The nurse documents the medication change in the MAR and notifies the physician. The next day, blood pressure is monitored, and the physician is consulted to discuss the resident's response to the dosage adjustment.

Illustration: A flowchart demonstrating the process from identifying a need for medication change, documenting the change, conducting follow-up actions, and documenting the outcome.

The Step-by-Step Coding Guide for item N2003 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.