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)

Discussion

Template: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? Ttenbergen 17:05, 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

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

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

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

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.