Admit Diagnosis: Difference between revisions

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''For other diagnoses, see [[Comorbid Diagnosis]] and [[Acquired Diagnosis / Complication]].''

'''Admit diagnoses''' are what led to the patient's ~~admission to your unit~~. ~~The '''most responsible reason''' why the patient was admitted should be given the highest priority on the PDA and in Access. In other words, for~~ the admit ~~diagnosis, the~~ "~~worst" problem is first~~. ~~This results in that diagnosis being put into ''"slot one"'' in~~ [[~~TMSX~~]].

'''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.

== ~~Admit Diagnosis coding restrictions by admit-from location~~ ==

== Collection Instructions ==

''Note: this is a summary from the defunct article ''! Diagnostic Coding Pointers''. I am cleaning out that article and dispersing its contents to the respective articles. If necessary, please comment here. [[User:Ttenbergen|Ttenbergen]] 16:51, 25 July 2011 (CDT) ''

~~=== Discussion ===~~

~~I think the following instructions should be eliminated for the following reasons:~~

* they are too complex; as such people are going to misunderstand them or forget to apply them. Better to stick to the "most important rule" and supplement it with [[General Diagnosis Coding Guidelines]] (these may have to be amended)

* they make special cases out of some diagnoses while leaving others out. For example, why is the reason for a CABG self-evident, but not the reason for an appendectomy?

* some of these contradict the general definition of the admit diagnosis being the "most responsible" diagnosis; when our data is analyzed with that definition in mind then these rules will lead to misrepresentation

* some collectors will stick to these rules even if they get a sense that it will misrepresent the situation; others will code to make sense of the situation as suggested by [[General Diagnosis Coding Guidelines]], yet others will have missed either in all the information, so these rules don't necessarily result in clean data, even if that is the intent.

I think the rules should be deleted, and only the first paragraph of this article should count. If we have such a thing as "surgery wants to know what procedures happen" then mention that in the [[General_Diagnosis_Coding_Guidelines#Consider_what_we_use_the_data_for]] section, e.g. mention Dr Kumar's interest in infections and to code them preferentially even if something more urgent is present (if that's what we want to to) but keep it general.

* What are your thoughts? [[User:Ttenbergen|Ttenbergen]] 17:05, 25 July 2011 (CDT)

==Data Structure==

Admit Diagnoses are drawn from [[S_ICD10 table]] and stored in [[L_ICD10 table]].

==~~= Operating room =~~==

~~==== Non-Trauma====~~

*PROCEDURE(S) FOLLOWED BY THE REASON(S) FOR THE PROCEDURE

*EXCEPTIONS:

**CABG: SELF-EXPLANATORY NO REASON REQUIRED

**VALVE REPLACEMENT AND CABG: CODE HEART VALVE SURGERY CODE

**CABG SECOND FOLLOWED BY THE REASON OR HEART VALVE PROBLEM

~~==== Trauma====~~

~~USE TRAUMA CODES "POST OP" FIRST FOLLOWED BY TRAUMA CODES "NON POST OP" FOR SIGNIFICANT INJURIES NOT OPERATED ON.~~

* {{discussion}} is that true? What if a less major problem was operated on - wouldn't we want to list the more-major unoperated problem higher? [[~~User:Ttenbergen|Ttenbergen~~]] ~~13:58, 27 July 2011 (CDT)~~

** actually, if I was right about the previous then the entire OR instructions could become something like "list procedure or trauma that was primary reason for OR, followed by other diagnoses or procedures in ~~order of their importance to the patient having been admitted" (feel free to tweak). [[User:Ttenbergen|Ttenbergen]] 14:00, 27 July 2011 (CDT)~~

~~=== Emergency Room===~~

~~==== Non-Trauma====~~

~~MOST RESPONSIBLE DIAGNOSIS FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM~~

~~==== Trauma====~~

~~MOST SIGNIFICANT PRIMARY INJURY FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM~~

* {{discussion}} is that true? Wouldn't we code a "shock" before a broken leg? [[~~User:Ttenbergen|Ttenbergen~~]] ~~13:56, 27 July 2011 (CDT)~~

** again, if I am right about that, then the instructions could be brought back to the standard most important first, nothing special about ER admission. ~~[[User:Ttenbergen|Ttenbergen]] 14:01, 27 July 2011 (CDT)~~

==== ~~Angio Lab==~~==

== Legacy Information ==

~~EMERGENCY ROOM TO ANGIO-LAB FROM ER TO WARD OR UNIT: LIST PRIMARY PROCEDURE FIRST:ANGIOGRAM FOLLOWED BY ANGIOPLASTY AND THEN STENT IF DONE~~. ~~FOLLOWED BY PROBLEM OR REASON FOR THE ANGIOGRAM (POSTINFARCT ANGINA/CHF~~,~~ETC) FOLLOWED BY REASON~~ (~~TYPE OF MI~~) ~~FOLLOWED BY THROMBOLYTICS IF APPLICABLE~~. ~~EXCEPTION: IF CARDIOGENIC SHOCK OR CARDIAC ARREST IN ER OR ANGIO LAB LIST AS #1 REASON FOR ADMISSION~~

{{Collapsable

| always= Maximum Number of Admit Diagnoses

| 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]]. }}

~~=== Recovery Room===~~

LIST REASON FOR TRANSFER '''from''' RECOVER ROOM FOLLOWED BY SIGNIFICANT COMPLICATIONS INTRA-OP FOLLOWED BY SURGICAL PROCEDURE AND THEN THE REASON FOR THE SURGERY (EX.: #1) BPCONTROL #2) PAIN CONTROL POST-OP #3) WITNESSED (INTRA-OPERATIVE) CARDIAC ARREST #4) BOWEL RESECTION #5) BOWEL CA)

=== ~~Ward~~===

===Related articles ===

~~PRIMARY REASON TO UNIT FOLLOWED BY SECOND MOST SIGNIFICANT REASON TO UNIT AND THEN RECENT SURGERY (WITHIN 4 DAYS OR SIGNIFICANT TO REASON FOR ADMISSION) SHOULD BE IDENTIFIED LAST.~~

~~== Maximum Number of Admit Diagnoses==~~

The PDA and 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.

~~==Data Structure==~~

~~Admit Diagnoses are stored in [[L_Dxs]] on the PDA and in the [[CCMDB.mdb]].~~

[[Category: Diagnosis Coding | * ]]

[[Category:Data Collection Guide]]

[[Category: ~~Data Collection Guide~~ ]]

[[Category:ICD10]]

@@ Line 1: / Line 1: @@
 ''For other diagnoses, see [[Comorbid Diagnosis]] and [[Acquired Diagnosis / Complication]].''
-'''Admit diagnoses''' are what led to the patient's admission to your unit. The '''most responsible reason''' why the patient was admitted should be given the highest priority on the PDA and in Access. In other words, for the admit diagnosis, the "worst" problem is first. This results in that diagnosis being put into ''"slot one"'' in [[TMSX]].
+'''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.
-== Admit Diagnosis coding restrictions by admit-from location ==
+== Collection Instructions ==
-''Note: this is a summary from the defunct article ''! Diagnostic Coding Pointers''. I am cleaning out that article and dispersing its contents to the respective articles. If necessary, please comment here. [[User:Ttenbergen|Ttenbergen]] 16:51, 25 July 2011 (CDT) ''
+{{ICD10 Guideline Como vs Admit}}
-=== Discussion ===
+{{ICD10 Guideline Admit vs Acquired}}
-{{discussion}}
-I think the following instructions should be eliminated for the following reasons:
-* they are too complex; as such people are going to misunderstand them or forget to apply them. Better to stick to the "most important rule" and supplement it with [[General Diagnosis Coding Guidelines]] (these may have to be amended)
-* they make special cases out of some diagnoses while leaving others out. For example, why is the reason for a CABG self-evident, but not the reason for an appendectomy?
-* some of these contradict the general definition of the admit diagnosis being the "most responsible" diagnosis; when our data is analyzed with that definition in mind then these rules will lead to misrepresentation
-* some collectors will stick to these rules even if they get a sense that it will misrepresent the situation; others will code to make sense of the situation as suggested by [[General Diagnosis Coding Guidelines]], yet others will have missed either in all the information, so these rules don't necessarily result in clean data, even if that is the intent.
-I think the rules should be deleted, and only the first paragraph of this article should count. If we have such a thing as "surgery wants to know what procedures happen" then mention that in the [[General_Diagnosis_Coding_Guidelines#Consider_what_we_use_the_data_for]] section, e.g. mention Dr Kumar's interest in infections and to code them preferentially even if something more urgent is present (if that's what we want to to) but keep it general.
-* What are your thoughts? [[User:Ttenbergen|Ttenbergen]] 17:05, 25 July 2011 (CDT)
+==Data Structure==
+Admit Diagnoses are drawn from [[S_ICD10 table]] and stored in [[L_ICD10 table]].
-=== Operating room ===
-==== Non-Trauma====
-*PROCEDURE(S) FOLLOWED BY THE REASON(S) FOR THE PROCEDURE
-*EXCEPTIONS:
-**CABG: SELF-EXPLANATORY NO REASON REQUIRED
-**VALVE REPLACEMENT AND CABG: CODE HEART VALVE SURGERY CODE
-**CABG SECOND FOLLOWED BY THE REASON OR HEART VALVE PROBLEM
-==== Trauma====
-USE TRAUMA CODES "POST OP" FIRST FOLLOWED BY TRAUMA CODES "NON POST OP" FOR SIGNIFICANT INJURIES NOT OPERATED ON.
-* {{discussion}} is that true? What if a less major problem was operated on - wouldn't we want to list the more-major unoperated problem higher? [[User:Ttenbergen|Ttenbergen]] 13:58, 27 July 2011 (CDT)
-** actually, if I was right about the previous then the entire OR instructions could become something like "list procedure or trauma that was primary reason for OR, followed by other diagnoses or procedures in order of their importance to the patient having been admitted" (feel free to tweak). [[User:Ttenbergen|Ttenbergen]] 14:00, 27 July 2011 (CDT)
-=== Emergency Room===
-==== Non-Trauma====
-MOST RESPONSIBLE DIAGNOSIS FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM
-==== Trauma====
-MOST SIGNIFICANT PRIMARY INJURY FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM
-* {{discussion}} is that true? Wouldn't we code a "shock" before a broken leg? [[User:Ttenbergen|Ttenbergen]] 13:56, 27 July 2011 (CDT)
-** again, if I am right about that, then the instructions could be brought back to the standard most important first, nothing special about ER admission. [[User:Ttenbergen|Ttenbergen]] 14:01, 27 July 2011 (CDT)
-==== Angio Lab====
+== Legacy Information ==
-EMERGENCY ROOM TO ANGIO-LAB FROM ER TO WARD OR UNIT:  LIST PRIMARY PROCEDURE FIRST:ANGIOGRAM FOLLOWED BY ANGIOPLASTY AND THEN STENT IF DONE. FOLLOWED BY PROBLEM OR REASON FOR THE ANGIOGRAM (POSTINFARCT ANGINA/CHF,ETC) FOLLOWED BY REASON (TYPE OF MI) FOLLOWED BY THROMBOLYTICS IF APPLICABLE. EXCEPTION:  IF CARDIOGENIC SHOCK OR CARDIAC ARREST IN ER OR ANGIO LAB LIST AS #1 REASON FOR ADMISSION
+{{Collapsable
+| always= Maximum Number of Admit Diagnoses
+| 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]]. }}
-=== Recovery Room===
+{{Data Integrity Check List}}
-LIST REASON FOR TRANSFER '''from''' RECOVER ROOM FOLLOWED BY SIGNIFICANT COMPLICATIONS INTRA-OP FOLLOWED BY SURGICAL PROCEDURE AND THEN THE REASON FOR THE SURGERY (EX.: #1) BPCONTROL #2) PAIN CONTROL POST-OP #3) WITNESSED (INTRA-OPERATIVE) CARDIAC ARREST #4) BOWEL RESECTION #5) BOWEL CA)
-=== Ward===
+===Related articles ===
-PRIMARY REASON TO UNIT  FOLLOWED BY SECOND MOST SIGNIFICANT REASON TO UNIT AND THEN RECENT SURGERY (WITHIN 4 DAYS OR SIGNIFICANT TO REASON FOR ADMISSION) SHOULD BE IDENTIFIED LAST.
+{{Related Articles}}
-== Maximum Number of Admit Diagnoses==
-The PDA and 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.
-==Data Structure==
-Admit Diagnoses are stored in [[L_Dxs]] on the PDA and in the [[CCMDB.mdb]].
-[[Category: Diagnosis Coding | * ]]
+[[Category:Data Collection Guide]]
-[[Category: Data Collection Guide ]]
+[[Category:ICD10]]