General Diagnosis Coding Guidelines

From CCMDB Wiki
Jump to navigationJump to search

I have linked this from Critical Care and Medicine Database Core Curriculum, but it likely needs updating. Unless we don't want it at all.

  • SMW

  • Cargo

  • Categories

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 the following points. Please consider all these points before requesting clarification from Trish.

For specific instructions, see Admit Diagnosis, Comorbid Diagnosis and Acquired Diagnosis / Complication.

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? Consider how our coded diagnoses are used and Use your best judgment.

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 the chart supports that the diagnosis is wrong fundamentally (not a similar dx of the same flavour), use your best judgement and talk to the doctor.
  • An exception to this "rule" is for diagnoses which have specific, standard criteria that are listed on the relevant wiki page. Examples include VAP and CLI.
    • Sometimes with these the physicians and others might be using different diagnoses from the ones we decided to use in the database.

Is the diagnosis highly likely

If the chart leaves some uncertainty about the true diagnosis, but it is very likely that a diagnosis is present, code it.

When in doubt, code it

Easier to exclude false positives than to catch false negatives.

If we code an ambiguous diagnosis, and it is false, then a chart review will find and eliminate that error.

If we don't code an ambiguous diagnosis, we will never find out about it.

Use your best judgment

All data collectors are ICU nurses. This decision was made because you guys know enough to know what the quack of a duck sounds like. So, try to make reasonable decisions. If you could make a good case to defend coding an ambiguous diagnosis, code it, and vice versa. If all we wanted was someone who can tell if a criteria we state is met, we could have hired less qualified staff.

Talk to the doctor

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.


  • These are meant to make your life easier. If you have concerns with them, as always, please post them here. Ttenbergen 15:35, 29 May 2009 (CDT)
So, collectors, almost 10 years after I initially asked that question, did these guidelines ever become useful?  
  • SMW

  • Cargo

  • Categories