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SECTION I: ACTIVE DIAGNOSES - MDS for Dummies

CMS s RAI Version Manual CH 3: MDS Items [I] October 2019 Page I-1 SECTION I: ACTIVE DIAGNOSES Intent: The items in this SECTION 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. I0020: Indicate the resident s primary medical condition category Item Rationale Health-related Quality of Life Disease processes can have a significant adverse effect on residents functional improvement.

Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the . last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and ...

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