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MDS 3.0 Tip: Section I, Active Disease Diagnosis, contains new time element and diagnoses

MDS 3.0 Update, February 23, 2009

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Under the most recent MDS 3.0 draft, Section I, Active Disease Diagnosis, contains some significant changes. Review Section I under the 3.0 draft to prepare for what might be in store under the final MDS 3.0.  

According to the draft, staff should check all “active diseases in the last 30 days.” This is a change from the MDS 2.0, which did not specify the 30-day time element. This may require nursing facility staff members to think more critically about disease diagnoses within the specified period. For example, if a resident suffered from a stroke three months prior to the assessment, you may code the late-effects the resident continues to suffer from, such as aphasia or right-sided hemiplegia, but the stroke diagnosis would no longer be coded.

A few other changes to note in the new Section I:

• The MDS 3.0 organizes the section differently than the MDS 2.0, combining the 2.0 items I1, diseases, and I2, infections, into one section
• The section introduces some new diagnoses, such as post-traumatic stress disorder
• Some MDS 2.0 diagnoses, such as sexually transmitted diseases and conjunctivitis, have been omitted

Remember, only a physician or physician extender can make or change a diagnosis. Your nursing facility’s clinical staff must confirm a diagnosis through a physician’s order. 

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