RE: Diagnosis

[Brenda Chance]

I don’t know how answered “absolutely” but you need to refer to the MDS manual.  The manual states to code any diagnoses in section I, that they “require a physician-documented diagnosis in the clinical record.  It is good clinical practice to have the resident’s physician provide supporting documentation for any diagnosis.”   Brenda W. Chance, RN, RAC-C MDS Coordinator     CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Sent: Friday, January 16, 2004 10:51 PM To: [EMAIL PROTECTED] Subject: Re: Diagnosis   In a message dated 1/16/2004 1:26:19 PM Pacific Standard Time, [EMAIL PROTECTED] writes: 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? Absolutely