Step-by-Step Coding Guide for Item Set X0700B: Correction: Discharge Date

1. Review of Medical Records

• Objective: Confirm that the discharge date recorded in the MDS accurately reflects the actual date the resident was discharged from the facility.
• Action: Examine the resident's discharge records, including hospital transfer documentation, nursing notes, and communications with care coordinators or family members.

2. Understanding Definitions

• Discharge Date: The official date when a resident was discharged from the facility, which is critical for accurate historical data, compliance reporting, and effective care transitions.

3. Coding Instructions

• Verify the Correct Discharge Date: Check the date listed in the MDS against official discharge documentation.
• Correct the Date in the MDS: If discrepancies are found, update the MDS to reflect the accurate discharge date, ensuring it aligns with documented evidence from the resident's file.

4. Coding Tips

• Cross-Verification: Ensure that the discharge date matches the date in all relevant medical and administrative documentation.
• Attention to Detail: Be meticulous in reviewing the discharge process documentation to avoid errors.

5. Documentation

• Record-Keeping: Keep detailed records of the original incorrect date and the corrected date, including the sources used for verification.
• Audit Trail: Document who made the correction, when it was made, and why the correction was necessary to maintain an audit trail for compliance and inspections.

6. Common Errors to Avoid

• Inaccurate Record Keeping: Ensure that the discharge date is not incorrectly recorded due to clerical errors or misinterpretation of documents.
• Failure to Update All Records: Once the discharge date is corrected in the MDS, ensure that all related documents and systems are updated to reflect the change to maintain consistency across all records.
• Delay in Corrections: Promptly address discrepancies as soon as they are identified to avoid complications with regulatory compliance and data integrity.

7. Practical Application

• Example: During a compliance audit, it is discovered that the MDS for resident Mark Thompson recorded a discharge date of June 15, 2024, while hospital records indicate he was actually discharged on June 12, 2024. The MDS Coordinator reviews the resident's file, confirms the discrepancy, and corrects the discharge date in the MDS to June 12, 2024. The correction is documented, including references to the hospital records as verification, and an entry is made in the facility's compliance log.

Please note that the information provided in this guide for MDS 3.0 Item set X0700B 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.