How should patient diagnoses and symptoms be assessed for M1021?

For M1021, patient diagnoses and symptoms should be assessed objectively through clinical tests and documentation. This approach ensures that the information gathered is based on measurable and verifiable data rather than personal opinions or perceptions. Clinical tests provide concrete evidence of the patient's condition and can help paint an accurate picture of their health. Documentation, which includes medical histories, previous assessments, and results from physical examinations, serves as a trustworthy source of information that can be consistently referenced.

Relying solely on the initial hospital visit would not capture any changes in the patient's condition over time and would provide an incomplete assessment. Subjective information from staff interviews can introduce bias and may not reflect the true clinical status of the patient. Feedback from family members can be valuable, but it does not replace the need for objective clinical evidence, as it is based on personal observations and experiences, which may not encompass the full clinical picture. Thus, using clinical tests and appropriate documentation is crucial for an accurate assessment in accordance with OASIS-E standards.