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. Planning for Care Indicate the resident s primary medical condition category that best describes the primary reason for the Medicare Part A stay.

diagnoses communicated verbally be documented in the medical record by the physician to ensure follow-up. • Diagnostic information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up. 2. Determine whether diagnoses are active:

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