0
No
if the facility did not contact the physician and complete prescribed/recommended actions in response to each identified potential or actual
clinically significant medication issue by midnight of
the next calendar day.
DiraChart MDS item reference
N2003Section Nv1.20.1Manual page N-22
Medication Follow-up
Item Rationale
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
Yes
if the facility contacted the physician AND completed the prescribed/recommended actions by midnight of the next calendar day after each potential or actual clinically significant medication
issue was identified.
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
This item is completed if one or more potential or actual clinically significant medication issues
were identified during the admission drug regimen review (N2001 = 1).
1. Review the resident’s medical record to determine whether the following criteria were met
for any potential or actual clinically significant medication issues that were identified upon
admission:
•
Two-way communication between the clinician(s) and the physician was completed by
midnight of the next calendar day, AND
•
All physician-prescribed/-recommended actions were completed by midnight of the next
calendar day.
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.
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.
DEFINITION
MEDICATION FOLLOW-
UP
The process of contacting a
physician to communicate an
identified medication issue
and completing all physician-
prescribed/recommended
actions by midnight of the
next calendar day at the
latest.
N2003: Medication Follow-up (cont.)
Coding Instructions
•
Code 0, No: if the facility did not contact the
physician and complete prescribed/recommended
actions in response to each identified potential or actual
clinically significant medication issue by midnight of
the next calendar day.
•
Code 1, Yes: if the facility contacted the physician
AND completed the prescribed/recommended actions
by midnight of the next calendar day after each
potential or actual clinically significant medication
issue was identified.
Coding Tips
•
If the physician prescribes/recommends an action that
will take longer than midnight of the next calendar day
to complete, then code 1, Yes, should still be
entered, if by midnight of the next calendar day the
facility has taken the appropriate steps to comply with
the prescribed/recommended action.
— Example of a physician-recommended action that
would take longer than midnight of the next
calendar day to complete:
o The physician writes an order instructing the clinician to monitor the medication
issue over the next three days and call if the problem persists.
—
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
Official CMS source
Verify in the CMS Source
Open the mapped manual or item-set location without losing your place on this item page.
Reference details
Deeper help after the reference answer
Open these tools when you need additional drilldown, CAA crosswalk, documentation, source-locator, or AI-context detail.