Adult Long-Term Care Functional Screen
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LTC FS Instructions Module 5: Diagnosis

Contents

Objectives

By the end of this module you should be able to:

  • Accurately complete the diagnosis section of the LTC FS.
  • Explain how to "confirm" or "verify" a diagnoses.

5.1 Diagnoses Must be Confirmed

Medical information is often not readily available when a screen is being done in a community setting. To accurately complete the Diagnoses section of the LTC FS, a screener must confirm the person's diagnoses.

Medical information is confirmed if it is:

  1. Stated to screener by a MD, RN, or other health care professional, or
  2. Copied from current health care records, or very clearly stated, in exact medical terms, by the person, family, guardian, advocate, etc. It is best practice to confirm diagnoses with written documentation from the person's health care provider(s).

The exceptions to these criteria are:

  • psychiatric diagnoses,
  • behavioral diagnoses,
  • dementia diagnoses, and
  • the diagnosis of intellectual disability.

People commonly say someone has "Alzheimer's," "anxiety," "depression," or "attention deficit/hyperactivity disorder," without a confirmed diagnosis. At times, a family member reports the person being screened has a diagnosis of intellectual disability or a psychiatric, behavioral, or dementia diagnosis when there is limited or no documentation to substantiate that diagnosis, and, the person's current functioning does not seem to match the usual functional limitations associated with that diagnosis.

While such statements may be helpful in the assessment process, they are insufficient evidence to support marking these diagnoses on the screen. A screener must confirm a psychiatric, behavioral, dementia, or intellectual disability diagnosis directly with a health care provider, medical record, the Children's Long Term Support Functional Screen, or the disability determination diagnosis from the Social Security Administration.

If a diagnosis can not be confirmed:
If after review of medical records and contact with health care providers it is determined the person has no current diagnosis, the screener must choose the "No current diagnoses" box. In addition, the screener should provide some detail regarding the absence of any diagnosis in the Notes section of the LTC FS. (Example: "After talking with Mr. Smith's doctor, it was determined that Mr. Smith has no diagnosis.")

If an individual refuses to see a health care professional and does not have any medical records to confirm a diagnosis, enter this information in the Notes section of the LTC FS. (Example: "Mr. Smith has not been to the doctor in over 30 years and refuses to be seen by a health care provider today.")

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5.2 Diagnoses Table Does Not Impact Eligibility

Completion of the LTC FS Diagnoses Table does not impact the eligibility determination; it is for research purposes only. However, the accurate documentation of diagnoses is very important to population profiles and to show that Family Care participants in community settings are similar to populations in long-term care facilities.

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5.3 Completing the Diagnoses Table

The Diagnoses Table is not meant to be all-inclusive; only some of the more common diagnoses are here. This table does include almost all of the diagnoses on the Minimum Data Set (MDS) form that nursing home staff must complete. It is permissible to refer to the MDS or any other health care providers' documentation to complete the table, but a screener must confirm that the information is still current. "Current" is defined as no more than 12 months old and still applicable. A screener needs to check with the person's health care provider(s) to confirm the medical information is still applicable.

On the Diagnoses Table, check ALL that apply.

For convenience, the diagnoses are grouped by major categories (e.g., Pulmonary, Cardiovascular, Neurological, etc.).

Use the "Diagnoses Cue Sheet" (PDF)" provided by the Department in order to determine which box to check for a given diagnosis not listed on this table.

For any diagnosis not listed on the Diagnoses Table, first see if it is listed on the Diagnoses Cue Sheet" (PDF). If it is, check the box indicated on the cue sheet.

REMINDER: If the diagnosis is not on the cue sheet, then a screener must check the K5: Other box and enter the name of the diagnosis in the space provided. A screener may not assign a Diagnosis Table category for a diagnosis not listed on the Diagnoses Cue Sheet.

Ongoing screen quality reviews indicate screeners are over-using the K5: Other box and are writing in diagnoses that are in fact already on the Diagnoses Cue Sheet. The number of synonyms and misspellings indicate screeners may not always be contacting health care professionals to confirm the diagnoses.

REMINDER: The selection of I3: Deaf is correct when the person's hearing loss cannot be overcome with hearing aids. And, the selection of I4: Other Sensory Disorders is correct when a person has a partial hearing deficit or when a person's hearing loss is able to be overcome with hearing aids.

REMINDER: The selection of I1: Blind is correct when the person's vision loss cannot be corrected to 20/200 or their visual field with both eyes is less than or equal to 20 degrees. And, the selection of I2: Visual Impairment is correct when a person's vision loss can be corrected to 20/200 or their visual field with both eyes is more than 20 degrees.

REMINDER: Do not interpret an individual's complaints or symptoms and enter unconfirmed diagnoses. In addition, do not infer an individual's diagnoses based on their prescribed medications. The same medication can be prescribed for a number of diagnoses or conditions.

  • Example A: An 82 year old woman has diabetes mellitus and is complaining of increasingly poor vision. The screener does NOT check I2: Visual Impairment (e.g., cataracts, retinopathy, glaucoma, macular degeneration) based solely on her self-report.

  • Example B: An adult daughter says her elderly father is "really losing it," and "He's getting Alzheimer's." The screener asks her if a doctor has made this diagnosis. She says, "No, father hasn't been to a doctor for awhile, but it's gotta be, he forgets so much now." The screener does NOT check E1: Alzheimer's Disease or E2: Other Irreversible Dementia. The screener will need to obtain a release of information in order to contact his doctor for the confirmation of his current diagnoses.

If an individual has no diagnoses, choose the "No current diagnoses" box.

Quality Assurance Checks: The LTC FS application will check to ensure that target group selections are supported/confirmed by selections on the Diagnosis Table. For example, selecting the "Terminal Condition" target group should be supported by the selection of K3: Terminal Illness" (prognosis < or = 12 months) and any related terminal illness diagnosis on the Diagnoses Table. If selections do not match, the LTC FS application will display a cross edit statement prompting the screener to correct the recorded information.

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Last Revised: August 15, 2014
Wisconsin Department of Health Services
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