0
No
if no clinically significant medication issues were identified during the drug regimen review.
DiraChart MDS item reference
N2001Section Nv1.20.1Manual page N-18
Drug Regimen Review
Complete only if A0310B = 01.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
Yes
if one or more clinically significant medication issues were identified during the drug regimen review.
9
NA
if the resident was not taking any medications at the time of the drug regimen review.
Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Complete a drug regimen review upon admission (start of SNF PPS stay) or as close to
the actual time of admission as possible to identify any potential or actual clinically
significant medication issues.
2. Review medical record documentation to determine whether a drug regimen review was
conducted upon admission (start of SNF PPS stay), or as close to the actual time of
admission as possible, to identify any potential or actual clinically significant medication
issues.
Medical record sources include medical records received from facilities where the resident
received health care, the resident’s most recent history and physical, transfer documents,
discharge summaries, medication lists/records, clinical progress notes, and other resources as
available.
3. Discussions (including with the acute care hospital, other staff and clinicians responsible for
completing the drug regimen review, the resident, and the resident’s family/significant other)
may supplement and/or clarify the information gleaned from the resident’s medical records.
4. Clinically significant medication issues may include, but are not limited to:
•
Medication prescribed despite documented medication allergy or prior adverse reaction.
•
Excessive or inadequate dose.
•
Adverse reactions to medication.
•
Ineffective drug therapy.
•
Drug interactions (serious drug-drug, drug-food, and drug-disease interactions).
•
Duplicate therapy (for example, generic-name and brand-name equivalent drugs are both
prescribed).
•
Wrong resident, drug, dose, route, and time errors.
•
Medication dose, frequency, route, or duration not consistent with resident’s condition,
manufacturer’s instructions, or applicable standards of practice.
•
Use of a medication without evidence of adequate indication for use.
•
Presence of a medical condition that may warrant medication therapy (e.g., a resident
with primary hypertension does not have an antihypertensive medication prescribed).
•
Omissions (medications missing from a prescribed regimen).
•
Nonadherence (purposeful or accidental).
N2001: Drug Regimen Review (cont.)
Coding Instructions
•
Code 0, No: if no clinically significant medication
issues were identified during the drug regimen review.
•
Code 1, Yes: if one or more clinically significant
medication issues were identified during the drug
regimen review.
•
Code 9, NA: if the resident was not taking any
medications at the time of the drug regimen review.
Coding Tips
•
A dash (–) value is a valid response for this item;
however, CMS expects dash use to be a rare
occurrence.
•
The drug regimen review includes all medications,
prescribed and over the counter (OTC), including
nutritional supplements, vitamins, and homeopathic and
herbal products, administered by any route. The drug
regimen review also includes total parenteral nutrition
(TPN) and oxygen.
•
Adverse drug reaction (ADR) is a form of adverse
consequence. It may be either a secondary effect of a
medication that is usually undesirable and different
from the therapeutic effect of the medication or any
response to a medication that is noxious and unintended
and occurs in doses for prophylaxis, diagnosis, or
treatment. The term “side effect” is often used
interchangeably with ADR; however, side effects are
but one of five ADR categories, the others being
hypersensitivity, idiosyncratic response, toxic reactions,
and adverse medication interactions. A side effect is an
expected, well-known reaction that occurs with a
predictable frequency and may or may not constitute an
adverse consequence.
DEFINITIONS
POTENTIAL OR
ACTUAL CLINICALLY
SIGNIFICANT
MEDICATION ISSUE
A clinically significant
medication issue is a
potential or actual issue that,
in the clinician’s professional
judgment, warrants physician
(or physician-designee)
communication and
completion of
prescribed/recommended
actions by midnight of the
next calendar day at the
latest.
“Clinically significant” means
effects, results, or
consequences that materially
affect or are likely to affect an
individual’s mental, physical,
or psychosocial well-being,
either positively, by
preventing a condition or
reducing a risk, or negatively,
by exacerbating, causing, or
contributing to a symptom,
illness, or decline in status.
Any circumstance that does
not require this immediate
attention is not considered a
potential or actual clinically
significant medication issue
for the purpose of the drug
regimen review items.
N2001: Drug Regimen Review (cont.)
MDS item matrixAssessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
7 relationships4 groups+
Assessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
Nursing Home Subsets
Swing Bed Subsets
Program and Policy Use
Item Subset Required Use ISC Skip Patterns
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