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Physical examination showed no pathologic findings, malaria was excluded by repeated thick blood smears, and in the absence of abnormal laboratory findings a common cold disease was assumed on clinical grounds. Laboratory findings revealed a leukocyte count of 12,400/mL, neutrophils of 9,200/mL, lymphocytes 2,300/mL, erythrocytes 4,000/mL, Hb 12 g/dL, Hct 35%, MCH 84 fl, platelets 645,000/mL, erythrocyte sedimentation rate 127 mm/h, and a CRP of 148 mg/L. Consider this example: MDS item 12j, urinary tract infection (UTI), has very specific coding instructions in the Resident Assessment Instrument (RAI) Users Manual, including the requirement for significant laboratory findings to be in the resident's record. |
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