If a new admission was diagnosed and treated for a UTI prior to admission, but there is not sufficient documentation to determine that UTI criteria (McGeer’s) was met, do I code it in Section I?
In the case of UTI diagnosis within 30 days of the admission ARD, UTI evidence-based criteria does not have to be met. The RAI User’s Manual has specific guidance for this situation on page I-13:
“If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork.”