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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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| ==Problems or Procedure '''prior to''' arrival onto unit== | | == Collection Instructions == |
| 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.
| | {{ICD10 Guideline Como vs Admit}} |
| *An example '''to code''' would be a patient admitted with a [[CAP]] to ICU who was intubated, ventilated and placed on antibiotics. They develop [[Tachyarrythmias | 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.
| | {{ICD10 Guideline Admit vs Acquired}} |
| *An example '''not to code''' would be 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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| == OR/RR ==
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| === Operating room and Trauma ===
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| * 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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| *** {{discussion}} I think that rule has been around since before I came on board. Julie, can we eliminate it? See also [[#Recovery Room]]Ttenbergen 17:35, 2017 September 6 (CDT)
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| *** Yes, I agree. --[[User:JMojica|JMojica]] 15:19, 2017 September 11 (CDT)
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| **** flagged for Trish for final vetting since this would be a change in collection practice. Ttenbergen 18:53, 2017 September 11 (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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| ** {{discussion}} Can from OR currently have somethign other than the surgery as primary admit diagnosis? If not this needs to be considered at same time as [[#Operating room and Trauma]].
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| ** Yes, should be similar as OR. --[[User:JMojica|JMojica]] 15:20, 2017 September 11 (CDT)
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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 |
| For some time [[CCMDB.mdb]] had been able to record any number of admit diagnoses. However, only the '''six (6)''' with the highest priority were appended to [[TMSX]]. | | | 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}} |
| = ICD 10 =
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| {{ICD10}} | |
| This is how this will be done in ICD10
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| Coding for admit dxs will follow the general [[ICD10 collection]] instructions.
| | ===Related articles === |
| | {{Related Articles}} |
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| {{discussion}} will there be any special considerations? Ttenbergen 00:55, 2017 September 23 (CDT)
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| ==Related articles ===
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| {{Related Articles}}
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| [[Category:Diagnosis Coding| *]]
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| [[Category:Data Collection Guide]] | | [[Category:Data Collection Guide]] |
| [[Category:ICD10]] | | [[Category:ICD10]] |