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

1. Review of Medical Records

• Objective: To ensure that the resident’s last name is correctly documented in the medical records.
• Steps:
  1. Access Records: Retrieve the resident’s medical records, admission forms, and any identification documents.
  2. Verify Accuracy: Cross-check the last name documented across various records (e.g., admission form, ID, previous MDS assessments).
  3. Identify Discrepancies: Look for any inconsistencies or errors in the last name spelling.

2. Understanding Definitions

• Correction: The process of updating or rectifying information that was previously recorded incorrectly.
• Resident Last Name: The family name or surname of the resident as documented in the facility records and official documents.

3. Coding Instructions

• Steps:
  1. Identify the Error: Determine the specific error in the resident’s last name that needs correction.
  2. Update the Record: Enter the correct last name in item set X0200C.
  3. Date and Sign: Ensure the correction is dated and signed by the person making the correction.
  4. Notify Relevant Parties: Inform relevant staff and departments of the correction to ensure consistency across all records.

4. Coding Tips

• Double-Check Spelling: Confirm the correct spelling of the resident’s last name using official documents (e.g., ID card, social security card).
• Consistency: Ensure the corrected last name is updated consistently across all sections of the medical record and MDS forms.
• Documentation: Keep a record of the correction process, including the reason for the correction and the documents used to verify the correct name.

5. Documentation

• Required:
  • Correction Form: A form or entry in the MDS indicating the correction of the last name.
  • Supporting Documents: Copies of official documents used to verify the correct last name (e.g., ID card, birth certificate).
  • Correction Log: A log documenting the date, reason, and person responsible for the correction.

6. Common Errors to Avoid

• Misspelling: Incorrectly spelling the last name during the correction process.
• Inconsistent Updates: Failing to update all instances of the last name in the medical records.
• Lack of Verification: Not verifying the correct last name with official documents.

7. Practical Application

• Example:
  • Initial Error: The resident, Mr. John Doe’s last name was incorrectly entered as “Doa” in the initial MDS assessment.
  • Review Process: Upon review, the error is identified by comparing the MDS record with Mr. Doe’s ID card, which shows the correct spelling “Doe”.
  • Correction:
    • Step 1: Access the MDS record and locate item set X0200C.
    • Step 2: Update the last name from “Doa” to “Doe”.
    • Step 3: Enter the date of correction and sign the entry.
    • Step 4: Update all relevant records and notify the administrative staff.
  • Documentation: The correction is documented in the correction log, including the date, reason, and documents used for verification.
• Illustration:
  • Provide a before-and-after example of the resident’s last name in the MDS form.
  • Include a sample correction form showing the updated last name.

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.