I did an audit and the provider is coming back and saying the patient had a stroke and difficulty swallowing and that is why they are being admitted to the NH. The provider is saying this could be high risk? However, in the CC/HPI area the patient states they are improving and in the assessment the patient’s status is fair. How would you determine a diagnosis to be high risk? Should the provider document something?

How would you determine what is high risk??

:confused: