Coding from HPI for LTC

bundydelly

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Hello All,

I work in LTC and I got a notification from one of my MDS nurses that they had added a dx of Dementia for a resident, but I did not have it on my diagnosis sheet for that particular resident. I went through all the documentation and could not find a dx or dx code of Dementia for said resident. I sent her an e-mail asking her where she found it, and she did. Out of 30+ encounters our physician's have had with this resident, plus hospital documentation, and the resident's 77/78, this is the ONLY thing indicating the dx of Dementia. The NP that saw her on this day didn't even give a dx code for it, which they usually do. Our social worker doesn't even have it on her 77.

History of Present Illness
Details:
Patient is seen today to review labs and for follow-up of
hypertension and leg edema. No concerns from nursing. Review
patient's weight shows she is down 2 pounds from last week. Labs
reviewed today sodium 140 potassium 3.6 BUN 30 creatinine 1.16
magnesium 1.9 vitamin D 46. Patient is pleasant denies concerns or
complaints, unreliable historian secondary to dementia. Medications
verified, as per MAR.


Can I code this on my diagnosis sheet? This one time small blurb? I go round and round with the MDS nurses on a daily basis in regards to coding, so I'm cautious.

Thank you,

Brandi McKessy, CPC
 
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