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Primary Admit Diagnosis: Difference between revisions

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moved example here from Dx Primary since all meaning-related info is consolidated here
phrased that more generically and put the example in a collapsable. pls tweak if I did not capture the intent
 
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The Primary Admit Dx (Most Responsible Diagnosis, MRDx)  is the dx most responsible for an admission to that unit/ward. See [[Dx Primary]] for details on how it is collected.
The Primary Admit Dx (Most Responsible Diagnosis, MRDx)  is the dx most responsible for an admission to that unit/ward. See [[Dx Primary]] for details on how it is entered into the collection tool.  
*When there are multiple competing diagnosis choose the diagnosis that is the most severe or responsible for the admission.  At times this may be difficult to determine, use your best clinical judgment based on the documentation.
*If multiple trauma is part of the admit diagnosis, then among this group of linked ICD10 codes, the Primary Admit Diagnosis would be either the Multiple trauma or the "worst" thing injured, e.g. Brain injury, diffuse (TBI), injury/trauma


{{DiscussTask|  
* When there are multiple competing diagnoses, choose the one that is the most severe or responsible for the admission.  At times this may be difficult to determine, use your best clinical judgment based on the documentation.
* Allan could you please provide some clarification on post op cardiac surgery patients? In the past (although I cannot find a reference on the wiki) we were instructed to mark the primary as the reason for the procedure or long ago (before CCI) the surgery itself. This somehow does not feel correct. for example  a post op CABG comes out on pressors, with a pa catheter and reduced CO/CI and is in cardiogenic shock, we use the [[Iatrogenic, hypotension/shock, postoperative/post-procedural]] and also code [[Shock, cardiogenic]] and link it with [[Coronary artery disease, chronic (atherosclerosis, chronic ischemic heart disease)|Coronary artery disease, chronic]] and [[Angina pectoris, stable or NOS]] or [[Angina pectoris, unstable]]  It seems to me that the primary should be the cardiogenic shock?  but if the same patient comes out on pressors for a few hours, I would use the [[Iatrogenic, hypotension/shock, postoperative/post-procedural]] but would not necessarily code it as primary?  IF the same patient comes out with no pressors, I would check the primary as the angina or CAD .  I think some of the confusion comes from the fact that all CABG patients and post op valves are admitted to ICCS/ccu and some are quite stable, while other are not, but we need a rule so we code this consistently [[User:Lkaita|Lisa Kaita]] 11:38, 24 December 2025 (CST)
{{Ex |  
** I moved this from the [[Dx Primary]] page which explains how to collect this to this page. It was split out long ago since it combines a few different concepts. Documentation about how to decide what this is should live on this page. [[User:Ttenbergen|Ttenbergen]] 13:25, 24 December 2025 (CST)
* Admitted with: Pneumonia, NOS which is noted to be not severe, and CVA which is severe 
** Primary Reason to be checked off:  CVA. }}
* If multiple trauma is the main reason for admission there will be a group of linked ICD10 codes that make up the [[Admit Diagnosis]]; the Primary Admit Diagnosis would be either the [[Multiple trauma]] or the "worst" thing injured, e.g. [[Brain injury, diffuse (TBI), injury/trauma]]
* For a patient admitted after a procedure, for a routine procedure without complications chose the diagnosis that required the procedure; if complications after the procedure were the reasons for admission then code those.
{{Ex | elective CABG to ICCS
**if routine with no complications primary would be [[Coronary artery disease, chronic (atherosclerosis, chronic ischemic heart disease)|Coronary artery disease, chronic]],
**if elective but on pressors for a few hours , but no [[Shock, cardiogenic]] link the [[Iatrogenic, hypotension/shock, postoperative/post-procedural]] with [[Coronary artery disease, chronic (atherosclerosis, chronic ischemic heart disease)|Coronary artery disease, chronic]] and check the [[Iatrogenic, hypotension/shock, postoperative/post-procedural]] as primary,  
**if elective CABG but are unstable post op and meet the criteria for [[Shock, cardiogenic]] then link this diagnosis with [[Coronary artery disease, chronic (atherosclerosis, chronic ischemic heart disease)|Coronary artery disease, chronic]] and [[Iatrogenic, hypotension/shock, postoperative/post-procedural]] and check the cardiogenic shock as the primary diagnosis.
}}
}}
{{Ex | Admitted with: Pneumonia, NOS which is noted to be not severe, and CVA which is severe 
**Primary Reason to be checked off:  CVA.  }}


== Data use ==
== Data use ==
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