General Diagnosis Coding Guidelines: Difference between revisions
Ttenbergen (talk | contribs) m New page: There are cases where a diagnosis may not meet all criteria we set out for it in the code book. Instead of basing the decisions solely on criteria in the code book, please also consider th... |
Ttenbergen (talk | contribs) New directions to supplement diagnosis coding criteria |
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== Consider what we use the data for == | == Consider what we use the data for == | ||
When you code a diagnosis, consider what the database '''uses''' it for. Would someone be able to generate some meaning from your entry later? [[General Diagnosis Coding Guidelines#Use your best judgment]]. | When you code a diagnosis, consider what the database '''uses''' it for. Would someone be able to generate some meaning from your entry later? [[General Diagnosis Coding Guidelines#Use your best judgment|Use your best judgment]]. | ||
== If the doctor says so, it probably is == | == If the doctor says so, it probably is == | ||
If a doctor diagnoses a condition when our guide criteria are not fully met, code it. | If a doctor diagnoses a condition when our guide criteria are not fully met, code it. | ||
If the chart supports that the diagnosis is wrong fundamentally (not a similar dx of the same flavour), [[General Diagnosis Coding Guidelines#use your best judgement]] and [[General Diagnosis Coding Guidelines#Talk to the doctor]]. | If the chart supports that the diagnosis is wrong fundamentally (not a similar dx of the same flavour), [[General Diagnosis Coding Guidelines#Use your best judgment | use your best judgement]] and [[General Diagnosis Coding Guidelines#Talk to the doctor | talk to the doctor]]. | ||
== Is the diagnosis highly likely == | == Is the diagnosis highly likely == | ||
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If you are unsure about a diagnosis, talk to the ward staff or the doctor. There have been negative reactions to this from some doctors in the past. Dr. Roberts wants to assure you that you have full backing from him if this happens. If you respectfully approach a doctor with a concern about collecting data on a chart, and the doctor is not professional about providing an answer, please email Dr. Roberts and Trish about this and Dr. Roberts will intervene. | If you are unsure about a diagnosis, talk to the ward staff or the doctor. There have been negative reactions to this from some doctors in the past. Dr. Roberts wants to assure you that you have full backing from him if this happens. If you respectfully approach a doctor with a concern about collecting data on a chart, and the doctor is not professional about providing an answer, please email Dr. Roberts and Trish about this and Dr. Roberts will intervene. | ||
An email will also be sent out to doctors to remind them that cooperation with data collectors is mandatory. | An email will also be sent out to doctors to remind them that cooperation with data collectors is mandatory. | ||
== Discussion == | |||
* These are meant to make your life easier. If you have concerns with them, as always, please post them here. [[User:Ttenbergen|Ttenbergen]] 15:35, 29 May 2009 (CDT) | |||
[[Category: Diagnosis Coding | *]] | [[Category: Diagnosis Coding | *]] | ||