If a patient denies dyspnea but exhibits signs when ambulating, what should you do with M1400 response code?

In this scenario, the patient may be denying awareness of dyspnea, but the observable signs of dyspnea during ambulation indicate a discrepancy between the patient's perceived experience and the actual clinical evidence. The M1400 response code pertains to the assessment of dyspnea, and when physical signs of dyspnea are evident upon exertion, it is appropriate to document this by changing the M1400 response code to a higher value that accurately reflects the patient's condition.

By changing the M1400 response code to a 2, you are indicating that the patient experiences dyspnea with exertion, despite their own denial of symptoms at rest. This coding ensures that the patient’s condition is correctly represented in the assessment data, which is crucial for both the clinical management of the patient and for accurate reporting and compliance with OASIS-E guidelines. Capturing this information is essential for providing appropriate care and planning further interventions, as it highlights potential needs for increased monitoring or therapy for the patient’s respiratory status.

In contrast, maintaining the code as 0 would misrepresent the patient’s condition, while codes 3 and a referral for further assessment may indicate a level of severity or necessity that does not align with the findings presented in this scenario.