This page addresses some of the most common questions that we have received about coding COVID-19 status on discharge when using the RAI-MDS 2.0 © (Resident Assessment Instrument–Minimum Data Set 2.0) and interRAI LTCF © (interRAI Long-Term Care Facilities).
General information
What is COVID-19?
COVID-19 (coronavirus disease 2019) is a disease caused by a new strain of coronavirus not previously identified in humans.
What change has CIHI made in response to COVID-19?
CIHI is implementing a new data element to collect information on a resident’s COVID-19 status at time of discharge, effective for discharges as of October 1, 2020. The new data element — COVID-19 Status — will be added to the Discharge Record (Continuing Care Reporting System, or CCRS) and Discharge Assessment and Discharge Tracking (Integrated interRAI Reporting System, or IRRS).
COVID-19 documentation and lab test results
How do I code this item when there is documentation that the test has been performed but there are no lab results available at the time of discharge?
If there are no test results documented in the clinical record, code 3 (No results).
How do I code this item when the official lab results are not available but there is other current documentation of the test results in the clinical record?
Documentation by a physician or by infection control staff indicating confirmed positive or negative test results for COVID-19 may be used to identify the most appropriate coding response. A confirmed case of COVID-19 is supported by a positive COVID-19 lab test result, and a suspected case of COVID-19 is ruled out by a negative COVID-19 lab result.
How do I code this item for a person who re-tests positive but remains asymptomatic 14 days after the last test result?
Code 0 (Positive test) based on the most recent test result. This data element is not intended to capture the severity of clinical signs or symptoms.
The person tested positive for COVID-19 and has been isolated/quarantined for 14 days. No subsequent testing for COVID-19 has been performed. The person was not showing any signs or symptoms of the disease. How do I code this?
If the positive test occurred in the last 90 or 92 days, code 0 (Positive test). This data element is not intended to capture the severity of clinical signs or symptoms.
If the cause of death is not confirmed to be related to COVID-19, will this change how I code?
No. Data will not be collected in CCRS or IRRS on cause of death as determined by a medical officer or coroner. The intent of this data element is to capture COVID-19 status at the time of discharge based on the most recent test results.
How do I code this item for a person who was last tested before admission to our unit/facility?
Review information within the lookback period on testing status and complete the item based on the most recent test result(s), regardless of where the test was performed. There must be documentation in the person’s clinical record to identify that a test has occurred and the test results. If the person previously tested positive at another facility and has since tested negative within the lookback period, code 2 (Resolved — recovered from condition).
Does it matter if the person is now confirmed negative and the previous positive test result was more than 92 days ago?
Code 2 (Resolved — recovered from condition) based on the most recent test result over the last 90 or 92 days (or since last assessment).
Do I code this item based on the date the test was performed or the date the results were received?
Apply the lookback period of 90 or 92 days to the date the test was performed.
How do I code this item when the person presents with a symptom suggestive of COVID-19 (e.g., sore throat) and a COVID-19 test has been taken but results have not come back at the time of discharge?
A presumed or suspected case in the absence of any testing should be coded 4 (Not tested). If a presumed or suspected case has been tested and the results are not available, code 3 (No results).
COVID-19 Status data submission and reporting
If we are waiting for test results, should we delay reporting until we receive them?
Do not wait for results if that would delay completion of the discharge record. If there has been no previous testing and a test was performed prior to discharge and results are pending, code 3 (No results). Do not infer results of the test.
Will this item be specific to facilities with outbreaks, or does it apply to every facility reporting to CCRS or IRRS?
Information on COVID-19 status is to be captured for every person who is discharged from a facility reporting to CCRS or IRRS.
Will you be collecting information on people who have recovered from COVID-19 (e.g., a person who had COVID-19 on admission or developed the disease during their stay and recovered before being discharged)?
A person who tests negative following a previous positive test will be identified in the data as having recovered from COVID-19 during their stay.
Note that not all public health agencies’ guidelines require a negative test result for a case to be considered resolved. Follow the most recent definition of a resolved case of COVID-19 in your jurisdiction if it differs from CIHI’s guidelines for completing this data element.
Is this a temporary item until the COVID-19 pandemic is over?
The new data element and data collection guidelines will be reviewed when the need for information on status of COVID-19 changes in Canada.
Additional information
Data element name
R3c. COVID-19 Status (for CCRS/RAI-MDS 2.0)
R5. COVID-19 Status (for IRRS/interRAI LTCF)
Intent: To identify and document a person’s status at time of discharge, based on their last COVID-19 test
Definitions
- Positive Test
- Positive COVID-19 test result confirmed by laboratory results, regardless of severity of clinical signs or symptoms.
- Negative test — no previous positive test
- Negative COVID-19 test result, with no previous positive test result.
- Resolved — recovered from condition
- Negative COVID-19 test result after having had a confirmed positive COVID-19 test.
OR
Refer to your provincial guidelines for the most recent definition of a resolved case.
- No results
- Test was performed but results either are not available or are inconclusive. Person may be symptomatic or asymptomatic. Include presumed and suspected cases of COVID-19.
- Not tested
- No test was performed. Person may be symptomatic or asymptomatic. Include presumed and suspected cases of COVID-19.
Process: Review the clinical record. Collect information on the person’s COVID-19 status on discharge. Review information on the testing status in the last 92 days (for CCRS) or the last 90 days (for IRRS). Document based on the last test result(s). The person’s record must include documentation indicating that testing has occurred, as well as the results of the testing. Code for the most appropriate response.
Coding: Code for the appropriate response from available documentation.
0 Positive test
1 Negative test — no previous positive test
2 Resolved — recovered from condition
3 No results
4 Not tested
RAI-MDS 2.0 © RAI-MDS 2.0 © interRAI Corporation, Washington, D.C., 1995, 1997, 1999.Modified with permission for Canadian use under licence to the Canadian Institute for Health Information.
interRAI LTCF © interRAI LTCF © interRAI Corporation, Washington, D.C., 1990–2011. Modified with permission for Canadian use under licence to the Canadian Institute for Health Information. Canadianized items and their descriptions © Canadian Institute for Health Information, 2020.