Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency • Survey
Question 5 of 9: Is it appropriate to use diagnoses added by consulting physicians?
It is appropriate to use diagnoses added by consulting physicians, in addition to those listed by the admitting physician and those identified by non-physician providers such as nurse practitioners and physician assistants. According to the RAI User’s Manual, active diagnoses are intended to code diseases that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death.
One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident’s current health status. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.
Direction from the RAI User’s Manual indicates that the medical record should be carefully and comprehensively reviewed to assure appropriate capture of all active diagnoses, which includes the physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
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