Admitting Dx

[smithand]

Hello everyone

I am looking for CMS regulation regarding Admitting diagnosis. Patient was admitted from hospital to our facility and nurses put Admitted diagnosis as Dehydration. I have been told I cannot change admitted dx. Per hospital discharge record and H/P progress note Dehydration was resolved when patient was admitted to our facility. I have already submitted admission assessment, but now I am thinking to modify my assessment and change the admitted dx.

[Talino]

The definition is explained fairly clear in the RAI, pI-3

"Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses."

The nurse simply entered a diagnosis from a hosp record. Whether that diagnosis is active or not, only when validated by a physician should you code it in the MDS.