Understanding and Coding MDS 3.0 Item N2001: Drug Regimen Review

Understanding and Coding MDS 3.0 Item N2001: Drug Regimen Review

Introduction

Purpose:
A comprehensive drug regimen review is critical for identifying and addressing potential medication-related issues that can affect a resident’s health. MDS Item N2001, Drug Regimen Review, is used to document whether a resident's entire drug regimen was reviewed for clinically significant medication issues at the time of admission, reentry, or significant change in status. Accurate coding of this item helps ensure that residents are receiving appropriate medication therapy and that any potential issues are identified and addressed promptly. This article provides detailed guidance on how to correctly code this item according to the latest MDS 3.0 guidelines.

What is MDS Item N2001?

Explanation:
MDS Item N2001, Drug Regimen Review, tracks whether the healthcare team performed a comprehensive review of the resident’s medications at the time of admission or a significant change in status. This review involves evaluating all prescription medications, over-the-counter drugs, supplements, and herbal products for potential adverse effects, drug interactions, contraindications, or any other clinically significant issues that could affect the resident’s health.

The documentation of this review helps ensure that residents receive optimal pharmacotherapy and that any medication-related problems are addressed as part of their care plan.

Guidelines for Coding N2001

Coding Instructions:
To correctly code Item N2001, follow these steps:

1. Review the Resident’s Medication Records:

   • Evaluate whether the drug regimen review was completed during the admission or significant change in the resident’s status.
   • The review should include all medications the resident is taking, including prescription drugs, over-the-counter medications, supplements, and herbal treatments.

2. Determine the Appropriate Response:

   • Code “0” if no drug regimen review was conducted at admission or upon significant status change.
   • Code “1” if a drug regimen review was completed, and no clinically significant medication issues were identified.
   • Code “2” if a drug regimen review was conducted, and a clinically significant medication issue was identified.

3. Enter the Response in Item N2001:

   • Record the appropriate code (0, 1, or 2) based on whether a drug regimen review was performed and if any issues were found.

Example Scenario:
A resident was admitted to the facility with several chronic conditions and a long list of medications. During the drug regimen review, the healthcare team identified a potentially dangerous interaction between two medications. They adjusted the treatment plan accordingly to avoid this interaction. In this case, 2 would be entered in Item N2001 to indicate that a clinically significant medication issue was identified and addressed.

Best Practices for Accurate Coding

Documentation:

• Ensure that the drug regimen review is thoroughly documented in the resident’s medical records, including any identified issues, interventions, and follow-up actions.
• If no clinically significant issues are identified, it should still be noted in the record that the review was conducted, and no changes were necessary.

Communication:

• Facilitate communication between healthcare providers, pharmacists, and the interdisciplinary team to ensure that the drug regimen review is discussed and documented.
• If a clinically significant issue is identified, ensure that all relevant team members are informed, and the resident’s care plan is adjusted accordingly.

Regular Audits:

• Conduct regular audits of drug regimen reviews to ensure that they are being completed as required and that any identified medication-related issues are properly documented in Item N2001.
• Address any discrepancies promptly to ensure compliance with medication management protocols and improve resident safety.

Conclusion

Summary:
MDS Item N2001 is essential for documenting whether a drug regimen review was conducted at the time of admission or significant change in status and whether any clinically significant medication issues were identified. Accurate coding of this item helps ensure that residents receive appropriate medications and that potential drug-related problems are promptly addressed. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure that drug regimen reviews are effectively managed and documented, supporting high-quality resident care.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-165] for detailed guidelines on conducting and documenting drug regimen reviews.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item N2001: Drug Regimen Review 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.