MDS Alert

Published on Wed May 08, 2019 PDF

Question: One of the residents in my facility uses melatonin a few times a week. Do I code that as a medication in Section N on the MDS?

Kansas Subscriber

Answer: Although melatonin comes in pill form and in a pill bottle, you should not code it in Section N (Medications) or anywhere else on the MDS.

“Herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug Administration (FDA). These products are not regulated by the FDA (e.g., they are not reviewed for safety and effectiveness like medications) and their composition is not standardized (e.g., the composition varies among manufacturers). Therefore, they should not be counted as medications (e.g., melatonin, chamomile, valerian root),” says the RAI Manual, on page N-10.

However, it is important to document a resident’s usage of melatonin (or the other aforementioned products) elsewhere on that resident’s clinical record to monitor usage and to keep an eye on whether there are any interactions with medications.

If a resident is having trouble sleeping and wants to stop taking melatonin or any of the other products just mentioned, the person or people responsible for care planning should take sleep hygiene into account.