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DiraChart MDS item reference
I6100Section Iv1.20.1Manual page I-5
Post-traumatic stress disorder (PTSD)
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
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Item-specific instructions
Coding Guidance
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Steps for Assessment
There are two look-back periods for this section:
•
Diagnosis identification (Step 1) is a 60-day look-back
period.
•
Diagnosis status: Active or Inactive (Step 2) is a 7-day
look-back period (except for Item I2300 UTI, which
does not use the active 7-day look-back period).
1. 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 physical,
transfer documents, discharge summaries, diagnosis/
problem list, and other resources as available. If a
diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.
•
Although open communication regarding diagnostic information between the physician
and other members of the interdisciplinary team is important, it is also essential that
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: 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.
DEFINITIONS
ACTIVE DIAGNOSES
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.
FUNCTIONAL
LIMITATIONS
Loss of range of motion,
contractures, muscle
weakness, fatigue,
decreased ability to perform
ADLs, paresis, or paralysis.
NURSING MONITORING
Nursing Monitoring includes
clinical monitoring by a
licensed nurse (e.g., serial
blood pressure evaluations,
medication management,
etc.).
I0100–I8000: Active Diagnoses in the Last 7 Days (cont.)
•
Item I2300 UTI, has specific coding criteria and does not use the active 7-day look-back.
Please refer to Page I-13 for specific
Coding Instructions
for Item I2300 UTI.
•
Check the following information sources in the medical record for the last 7 daysto
identify active” diagnoses: transfer documents, physician progress notes, recenthistory
andhistory andphysical, recent discharge summaries, nursing assessments, nursing care plans,
medication sheets, doctor’s orders, consults and official diagnostic reports, aother
sources as available.
Coding Instructions
Code diseases that have a documented diagnosis in the last 60 days and 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 during the 7-day look-back period
(except Item I2300 UTI, which does not use the active diagnosis 7-day look-back. Please refer to
Item I2300 UTI, Page I-14 for specific coding instructions).
•
Document active diagnoses on the MDS as follows:
— Diagnoses are listed by major disease category: Cancer; Heart/Circulation;
Gastrointestinal; Genitourinary; Infections; Metabolic; Musculoskeletal;
Neurological; Nutritional; Psychiatric/Mood Disorder; Pulmonary; and Vision.
—
Coding Tips
The following indicators may assist assessors in determining whether a diagnosis should be
coded as active in the MDS.
•
There may be specific documentation in the medical record by a physician, nurse
practitioner, physician assistant, or clinical nurse specialist of active diagnosis.
— The physician may specifically indicate that a condition is active. Specific
documentation may be found in progress notes, most recent history and physical,
transfer notes, hospital discharge summary, etc.
— For example, the physician documents that the resident has inadequately controlled
hypertension and will modify medications. This would be sufficient documentation of
active disease and would require no additional confirmation.
•
In the absence of specific documentation that a disease is active, the following
indicators may be used to confirm active disease:
— Recent onset or acute exacerbation of the disease or condition indicated by a positive
study, test or procedure, hospitalization for acute symptoms and/or recent change in
therapy in the last 7 days.
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