Admit Diagnosis

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 Diagnosis coding restrictions by admit-from location

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

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.

EMERGENCY ROOM:

NONTRAUMA

MOST RESPONSIBLE DIAGNOSIS FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM ====TRAUMA==== MOST SIGNIFICANT PRIMARY INJURY FIRST FOLLOWED BY THE SECOND MOST COMPROMISING PROBLEM

Angio Lab

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

RECOVER 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:

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.