Step-by-Step Coding Guide for N2005. Medication Intervention

1. Review of Medical Records

• Objective: Look for documented evidence of medication interventions in response to identified medication issues. This includes changes to medication orders, adjustments in dosage, or initiation of new medications aimed at addressing specific health concerns.
• Process: Examine nursing notes, pharmacy reports, physician orders, and medication administration records (MARs) for any changes or interventions related to the resident's medication regimen within the last 5 days.

2. Understanding Definitions

• Medication Intervention: Any action taken to address a potential or actual clinically significant medication issue. This could involve altering the medication regimen, adjusting dosages, discontinuing medications, or starting new medications to optimize the resident's health and safety.

3. Coding Instructions

• Code 0, No: Indicate this if no medication interventions were necessary or conducted in response to identified medication issues during the last 5 days.
• Code 1, Yes: Select this if one or more medication interventions were carried out within the last 5 days to address identified medication issues.

4. Coding Tips

• Ensure accuracy by confirming that documented interventions specifically address identified medication issues.
• Consult with pharmacy services or medication review committees if available, for insights into interventions made.
• Understand that not all medication changes constitute an "intervention" as defined; the change must be in response to a specific, identified issue.

5. Documentation

• Clearly document the identified medication issue, the intervention taken, and the rationale behind the intervention in the resident's medical records.
• If an intervention was made, detail the expected outcomes and any follow-up actions planned or needed.

6. Common Errors to Avoid

• Misinterpreting medication changes: Not all changes in medication are interventions related to specific problems. Ensure the change is a direct response to an identified issue.
• Overlooking documentation: Failing to review or document all sources that might indicate a medication intervention, such as communication logs with pharmacy services.

7. Practical Application

Example Scenario: A resident was experiencing increased drowsiness and confusion after starting a new antipsychotic medication. The healthcare team, upon review, identified the medication as the likely cause. The decision was made to reduce the dosage and monitor the resident for improvements.

• Documentation: This intervention, along with the rationale and expected outcomes, is documented in the resident's medical record.
• Coding: N2005 is coded as "1, Yes," indicating that a medication intervention was carried out in response to an identified issue.

The Step-by-Step Coding Guide for item N2005 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.