Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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Medication Follow-up
Item Rationale
Matrix review
4 matrix group(s) are already attached for review on this item.
Answer coverage
2 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if the facility did not contact the physician and complete prescribed/recommended actions in response to each identified potential or actua...
Code 1
Yes
if the facility contacted the physician AND completed the prescribed/recommended actions by midnight of the next calendar day after each po...
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section N and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page N-22
- CMS exact locator: Manual page N-22
- This item has 2 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page N-22
CMS exact locator
Manual page N-22
Full CMS Text
Item Rationale
Health-related Quality of Life
Integral to the process of safe medication administration practice is timely communication with a physician when a potential or actual clinically significant medication issue has been identified. Physician-prescribed/recommended actions in response to identified potential or actual clinically significant medication issues must be completed by the clinician in a time frame that maximizes the reduction in risk for medication errors and resident harm.
Planning for Care
When a potential or actual clinically significant medication issue is identified, prompt communication with the physician and implementation of prescribed actions is necessary to protect the health and safety of the resident.
Steps for Assessment
This item is completed if one or more potential or actual clinically significant medication issues were identified during the admission drug regimen review (N2001 = 1).
1. Review the resident’s medical record to determine whether the following criteria were met
for any potential or actual clinically significant medication issues that were identified upon admission: 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. 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.
DEFINITION
MEDICATION FOLLOW- The process of contacting a physician to communicate an identified medication issue and completing all physician- prescribed/recommended actions by midnight of the next calendar day at the latest.
Coding Instructions
Code 0, No: if the facility did not contact the
physician and complete prescribed/recommended actions in response to each identified potential or actual clinically significant medication issue by midnight of the next calendar day.
Code 1, Yes: if the facility contacted the physician
AND completed the prescribed/recommended actions by midnight of the next calendar day after each potential or actual clinically significant medication issue was identified.
Coding Tips
If the physician prescribes/recommends 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 facility has taken the appropriate steps to comply with the prescribed/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. — Examples of by midnight of the next calendar day: o A clinically significant medication issue is identified at 10:00 AM on 9/12/2017. The physician-prescribed/-recommended action is completed on or before 11:59 PM on 9/13/2017. o A clinically significant medication issue is identified at 11:00 PM on 9/12/2017. The physician-prescribed/-recommended action is completed on or before 11:59 PM on 9/13/2017. A dash (–) value is a valid response for this item; however, CMS expects dash use to be a rare occurrence.
DEFINITION
CONTACT WITH PHYSICIAN Communication with the physician to convey an identified potential or actual clinically significant medication issue, and a response from the physician to convey prescribed/recommended actions in response to the medication issue. Communication can be in person, by telephone, voice mail, electronic means, facsimile, or any other means that appropriately conveys the resident’s status.
Examples
1. Resident P was admitted to the nursing facility with active diagnoses of pneumonia and atrial
fibrillation. The acute care facility medication record indicated that Resident P was on a seven-day course of antibiotics and had three remaining days of this treatment plan. The nurse reviewing the discharge records from the acute care facility and the nursing facility admission medication orders noted that Resident P had an order for an anticoagulant medication that required INR monitoring, as well as the antibiotic. On the date of admission, the nurse contacted the physician responsible for Resident P and communicated a concern about a potential increase in Resident P’s INR with this combination of medications that could place them at greater risk for bleeding. The physician provided orders for laboratory testing so that Resident P’s INR levels would be monitored over the next three days, starting that day. However, the nurse did not request the first INR laboratory test until after midnight of the next calendar day.
Coding: N2003 would be coded 0, No.
Rationale: A potential clinically significant medication issue was identified during the
drug regimen review; the staff did contact the physician before midnight of the next calendar day, but did not complete, to the extent possible, the physician-prescribed actions related to the INR laboratory test until after midnight of the next calendar day.
2. Resident S was admitted to the facility from an acute care hospital. During the admitting
nurse’s review of Resident S’s hospital discharge records, it was noted that Resident S had been prescribed metformin. However, laboratory tests at admission indicated that Resident S had a serum creatinine of 2.4, consistent with renal insufficiency. The admitting nurse contacted the physician to ask whether this medication would be contraindicated with Resident S’s current serum creatinine level. Three hours after Resident S’s admission to the facility, the physician provided orders to discontinue the metformin and start Resident S on a short-acting sulfonylurea for ongoing diabetes management. These medication changes were implemented within the hour.
Coding: N2003 would be coded 1, Yes.
Rationale: A potential clinically significant medication issue was identified during the
drug regimen review; the physician communication occurred, and the nurse completed the physician-prescribed actions, by midnight of the next calendar day.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
QRP Quality Measures (Includes risk adjustment)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Item Subset Required Use ISC Skip Patterns
APU Item Admission (A0310B = 01)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
QRP PPS 5 Day Admission (A0310B = 01)
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4