Admit Diagnosis

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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 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.
  • 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.

OR/RR

Operating room and Trauma

  • 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.
    • 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.--LKolesar 13:41, 2017 August 24 (CDT)
      • Template:Discussion I think that rule has been around since before I came on board. Julie, can we eliminate it? See also #Recovery RoomTtenbergen 17:35, 2017 September 6 (CDT)
      • Yes, I agree. --JMojica 15:19, 2017 September 11 (CDT)

Recovery Room

  • 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.

Data Structure

Admit Diagnoses are stored in L Dxs.

Legacy Information

Maximum Number of Admit Diagnoses

Until we started to use Centralized data.mdb we were limited to 6 admit diagnoses. Was 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.