We were recently told by a utilization review team that we could not use resident/family stated previous weights for admission assessment/MDS completion. They said you could not code a significant weight loss using a stated weight, it had to be documented somewhere in the medical record. We were under the understanding that (as stated in the RAI User’s Manual) we can ask the “resident, family, or significant other” about weight loss and code as such for new admissions. What is the correct procedure?

Regulatory Specialist Diane Brown answers a visitor’s question about coding weight loss.