Admit Diagnosis: Difference between revisions
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==Problems or Procedure '''prior to''' arrival onto unit== | ==Problems or Procedure '''prior to''' arrival onto unit== | ||
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. | 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 '''to code''' would be a patient admitted with a [[CAP]] to ICU who was intubated, ventilated and placed on antibiotics. They develop [[ | *An example '''to code''' would be a patient admitted with a [[Community-acquired pneumonia (CAP) in ICD10|CAP]] to ICU who was intubated, ventilated and placed on antibiotics. They develop [[Atrial fibrillation and/or atrial flutter]] 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. | ||
*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. | *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. | ||
==Data Structure== | ==Data Structure== | ||
Admit Diagnoses are stored in [[ | Admit Diagnoses are stored in the [[L_ICD10 table]]. | ||
== Legacy Information == | == Legacy Information == | ||
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Until we started to use [[Centralized data.mdb]] we were limited to 6 admit diagnoses. | Until we started to use [[Centralized data.mdb]] we were limited to 6 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]]. | 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]]. | ||
===Related articles === | ===Related articles === | ||
Revision as of 08:48, 13 December 2017
For other diagnoses, see Comorbid Diagnosis and Acquired Diagnosis / Complication.
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.
Problems or Procedure prior to arrival onto unit
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 to code would be a patient admitted with a CAP to ICU who was intubated, ventilated and placed on antibiotics. They develop Atrial fibrillation and/or atrial flutter 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.
- 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.
Data Structure
Admit Diagnoses are stored in the L_ICD10 table.
Legacy Information
Maximum Number of Admit Diagnoses
Until we started to use Centralized data.mdb we were limited to 6 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.