Q:
The new MDS data element A2123 asks about the Provision of Current Reconciled Medication List to the Resident at Discharge. How is the current reconciled medication list defined and what information should be included?
A:
This data element is one of the new Standardized Patient Assessment Data Elements (SPADEs) on the MDS effective 10/2/2023. The coding of the item will be required for all Medicare Part A residents who are discharged from the SNF to the community at the end of a Part A stay. A current reconciled medication list is defined as a list of the resident’s current medications at the time of the discharged that reconciled by the facility prior to resident being discharged. The format and the content of the information provided is not regulated by CMS but is left to the discretion of the provider. Examples for information that may be included are provided in the draft version of the RAI Manual and include information about the following:
- The resident which may include the following: name, date of birth, active diagnoses, known medication and other allergies, and known drug sensitivities and reactions; and
- Each medication (prescribed and OTC), including the name, strength, dose, route of medication administration, frequency or timing, purpose/indication, and any special instructions. For any held medications, it may include the reason for holding the medication and when medication should resume and when the last dose of the medication was administered by the discharging provider; and when the final dose should be administered (e.g., end of treatment).
When providing this information to the resident, it is important to consider the resident’s response to the SODOH related to health literacy of the resident, which is addressed in a new item added to section B of the MDS and ask the resident how often they need assistance when reading instructions, pamphlets, or other written material from their doctor or pharmacy. It is recommended that the information provide use consumer friendly terminology and plain language to facilitate a clear understanding of the information provided.
Facilities should begin preparing now for the implementation of this new MDS data element by reviewing current the information that is provided to the resident at the time of discharge and determine what if any changes to this information need to be made the current policies and practices to effectively transfer this health information to the resident and/or subsequent provider at the time of discharge. The discharge process should identify how this information is collected and how the documentation will support that it was effectively communicated.
Interested in learning more about the MDS updates coming in October? Join us for the virtual workshop MDS Updates and Areas of Impact on July 19, 2023 for insights into the MDS 3.0 changes and guidance on action steps to take to effectively prepare.
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant
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