Step-by-Step Coding Guide for Item Set X0200C: Correction Resident Last Name

1. Review of Medical Records

• Objective: Verify the resident’s last name against multiple sources to ensure accuracy before entering or correcting it in the MDS.
• Action: Check the resident's last name against official documents such as government-issued ID (social security card, driver’s license), hospital records, and insurance documents.

2. Understanding Definitions

• Correction Resident Last Name: Refers to updating or correcting the resident’s last name in the MDS to reflect accurately on all legal and care documents.

3. Coding Instructions

• Enter Correct Last Name: Input the accurate last name of the resident as verified against official documentation. Ensure spelling is correct and aligns with the most formal source available.
• Documentation Field: Use the designated field in the MDS specifically for entering the corrected last name.

4. Coding Tips

• Consistency Check: Cross-reference the last name across all the resident's documentation within the facility to ensure uniformity.
• Privacy and Accuracy: Handle all documentation with care to maintain privacy and ensure data accuracy, especially when corrections are made.

5. Documentation

• Record-Keeping: Document the source of the correct last name and the reason for the correction in the resident’s file.
• Audit Trail: Maintain an audit trail that includes who made the correction, when it was made, and the evidence supporting the correction.

6. Common Errors to Avoid

• Incorrect Source Reference: Avoid using informal or second-hand sources for name verification.
• Typos: Ensure that the input does not contain typographical errors, which can lead to significant issues in care coordination and legal documentation.
• Incomplete Documentation: Always document the correction process fully, including justifications and authorizations.

7. Practical Application

• Example: During a routine review of resident files, it is discovered that the last name of resident John Doe was mistakenly recorded as “Doe” instead of the correct “Doe-Smith.” The error is identified through a comparison with John's social security card. The MDS Coordinator, upon verifying with other official documents, corrects the last name in the MDS to “Doe-Smith” on September 15, 2024, and notes this correction in the care plan and the facility’s compliance log.

Please note that the information provided in this guide for MDS 3.0 Item set X0200C was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. 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.