Long-Term Care Survey Alert

MDS Corner:

 What Do You Think? How Long Should You Code Pneumonia in Section I2 of the MDS?

Question: If a resident comes to the facility with a hospital diagnosis of pneumonia, how long should we code this diagnosis on the MDS?

Answer: If a resident's pneumonia treated in the hospital has resolved on the chest X-ray, but the person is still getting antibiotics -- and the nursing staff are monitoring his lung sounds and vital signs -- code the pneumonia diagnosis in Section I2, advises Rena Shephard, MHA, RN, RAC-CT, CE-NE, president and CEO of RRS Healthcare Consulting in San Diego, and founding chair of the American Association of Nurse Assessment Coordinators. However, I2 is really looking for an "active, acute condition," she adds. Thus, "once the resident's treatment is finished and the nursing staff isn't even monitoring [the person's] respiratory status any more than they monitor anyone else, you wouldn't code pneumonia anymore."

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