Q:
A new resident was admitted to our facility with an order for Mirtazapine 15mg every evening. There is no information in the admission paperwork regarding its use and the admitting nurse entered the order “for antidepressant.” Should N0415C2: High-Risk Drug Classes: Indication be coded “yes” or “no”?
A:
Based on the available information, N0415C2 should be coded “no.” A drug’s classification determines whether it is coded in N0415C1: High-Risk Drug Classes: Use, but a classification is not the same as an indication. For example, Mirtazapine, while being classified as an antidepressant, is also frequently used as an appetite stimulant in the long-term care setting. In this scenario, the indication, or why the resident is receiving this medication, is unclear.
According to the RAI manual (page N-6), an indication is defined as “The identified, documented clinical rationale for administering a medication that is based upon a physician’s (or prescriber’s) assessment of the resident’s condition and therapeutic goals.” In this case, the physician should be queried as to the indication for the medications use. Once this is documented, the order should be updated accordingly and item N0415C2 can then be coded “yes.”
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Chris Calo RN, BSN, RAC-CT
MDS Consultant
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