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| ''For other diagnoses, see [[Comorbid Diagnosis]] and [[Acquired Diagnosis / Complication]].'' | | ''For other diagnoses, see [[Comorbid Diagnosis]] and [[Acquired Diagnosis / Complication]].'' |
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| '''Admit diagnoses''' are what led to the patient's admission to your unit. We make special use of the [[Primary Admit Diagnosis]], so make sure the '''most responsible reason''' why the patient was admitted is given the highest priority. | | '''Admit diagnoses''' are what led to the start of the patient's current [[PatientFollow Project]] profile. An Admit Diagnosis is coded by setting the [[Dx_Type]] to "admit". We make special use of the [[Primary Admit Diagnosis]], so make sure you consider the content there. |
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| == Admit Diagnosis coding restrictions by admit-from location == | | == Collection Instructions == |
| | | {{ICD10 Guideline Como vs Admit}} |
| === Operating room and Trauma ===
| | {{ICD10 Guideline Admit vs Acquired}} |
| ** As I wrote in this section in 2011, there should be no special precedence for trauma codes or surgeries. The only reason we put the surgery first when they come from the OR is because CCMDB will not allow us to put a different code first. I stand by making diagnostic coding to have one rule for precedence and that is to put the most responsible diagnosis for admission first. Then follow this with all other issues priorizing for the specific patient. To make general rules does not make sense because every patient has to be priorized separately.
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| ** Right now for some reason we are forced to put the surgery first if the pt. comes from the OR, but this will all change with ICD 10 coding because diagnosis and procedures are put in separate bins.--[[User:LKolesar|LKolesar]] 13:41, 2017 August 24 (CDT)
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| === Recovery Room ===
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| *It is already clear that patients that come from recovery room may have a non-OR related diagnosis first. However, the coding rule should be still the same used for everyone, that is, the most responsible reason for admission to the ICU is the first diagnostic code.
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| === Emergency Room===
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| * Nothing to change about diagnostic coding rule.
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| ==== Angio Lab====
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| * Nothing to change about diagnostic coding rule. If the angio is prior to admission, then it is part of the admit diagnosis codes. If it happens after admission, it is part of the complications in our current coding structure. We do not need any special rules for order of diagnostic codes. --[[User:LKolesar|LKolesar]] 13:46, 2017 August 24 (CDT)
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| ===Problems or Procedure PRIOR TO arrival onto unit===
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| Any medical problems or procedures that a patient had done '''prior to''' their '''physical arrival''' into a medicine or ICU ward bed, and that '''are still relevant to the admission''' should be coded as part of admitting diagnosis and not as complications. Do not include old diagnoses that have been resolved. An example of this would be medicine patients who '''are "accepted" to medicine ward service but have not yet arrived on the ward''' (ie [[ER Wait]]).
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| *An example would be a patient admitted with a CAP to ICU who was intubated, ventilated and placed on antibiotics. They develop A fib and are placed on meds which may need adjusting because they are still having breakthrough rapid Afib. Once extubated they are often ready for the medicine ward but are still on antibiotics for their CAP and require watching to see if their Afib returns. The medicine collector would list both CAP and Afib as part of their admitting diagnoses.
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| *An example of a diagnosis that would not be listed is a patient with BPH who is not on any medications for it. They still have BPH but it is not an active problem being treated.
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| ==Data Structure== | | ==Data Structure== |
| Admit Diagnoses are stored in [[L Dxs]]. | | Admit Diagnoses are drawn from [[S_ICD10 table]] and stored in [[L_ICD10 table]]. |
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| == Legacy Information == | | == Legacy Information == |
| === Maximum Number of Admit Diagnoses ===
| | {{Collapsable |
| Until we started to use [[Centralized data.mdb]] we were limited to 6 admit diagnoses. | | | always= Maximum Number of Admit Diagnoses |
| Was ''The [[CCMDB.mdb]] can record any number of admit diagnoses. However, only the '''six (6)''' with the highest priority will be appended to [[TMSX]]. So, you can track as many diagnoses as you want as you go along, and then delete or re-prioritize to only send the most relevant.''
| | | full= |
| | Until we started to use [[Centralized_data.accdb]] we were limited to 6 admit diagnoses. |
| | For some time [[CCMDB.accdb]] had been able to record any number of admit diagnoses. However, only the '''six (6)''' with the highest priority were appended to [[TMSX]]. }} |
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| | {{Data Integrity Check List}} |
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| | ===Related articles === |
| | {{Related Articles}} |
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| [[Category:Diagnosis Coding| *]]
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| [[Category:Data Collection Guide]] | | [[Category:Data Collection Guide]] |
| | [[Category:ICD10]] |