Diagnoses can be coded in Section I only with a physician-documented diagnosis.  See page 3-127 of the RAI User's Manual.

Rena

Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
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Subj: Diagnosis
Date: 1/16/04 11:03:38 AM Pacific Standard Time
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                 If you have a patient and the physician does not document in H&P, or anywhere that they have hypothyroidism, and they are on Synthroid, would you code Hypothyroidism on the MDS?
Michelle




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