DiraChart MDS item reference
Complete only if A0310H = 1.
Use the item-specific response choices below when structured codes apply.
if the facility did not contact the physician and complete prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
if the facility contacted the physician and completed prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
if there were no potential or actual clinically significant medication issues
identified at admission or throughout the resident’s stay or the resident was not taking
any medications at admission or at any time throughout the stay.
Review what the item asks, how to choose the response, and what should be verified before submission.
The observation period for this item is from the date of admission (start of SNF PPS stay)
through discharge (Part A PPS discharge).
1. Review the resident’s medical record to determine whether the following criteria were met
for any potential and actual clinically significant medication issues that were identified upon
admission or at any time during the resident’s stay:
•
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.
N2005: Medication Intervention (cont.)
•
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.
•
Code 0, No: if the facility did not contact the physician and complete prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
•
Code 1, Yes: if the facility contacted the physician and completed prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
•
Code 9, NA: if there were no potential or actual clinically significant medication issues
identified at admission or throughout the resident’s stay or the resident was not taking
any medications at admission or at any time throughout the stay.
•
If the physician prescribes 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 clinician has taken the appropriate steps to comply with the
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.
—
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