MDS Alert

Published on Fri Jun 26, 2009 PDF

Question: What are the key mistakes facilities make in coding the number of medications at Section O1? How can we ensure accurate coding of this item?

Answer: Count all medications received by the resident in the sevenday assessment period, including those administered offsite (e.g., while receiving dialysis or chemotherapy), instructs the RAI User's Manual.

"The facility is responsible for communicating with the outpatient site to identify the use of any medications received while the resident was under their care, and for monitoring the effect, including any adverse effects, of medications after the resident's return to the facility," states the manual.

"If the resident received an injection of Vitamin B12 prior to the observation period, code it in Item O1. Vitamin B12 maintains a blood level, as do long acting antipsychotics. Determine if a specific long-acting medication is still active based on physician, pharmacist, and/or PDR input," states the manual.

Key point: To help ensure accuracy of the number of medications coded, look at the medication administration record -- not the physician order sheet, advises Marilyn Mines, RN, RAC-C, BC, in Deerfield, IL.

Tip: Count combination products, such as Corzide (which contains a diuretic and a beta-blocker) as one medication, states the manual. For additional instructions, see pages 3-178 to 3-181 of the RAI User's Manual.