General Diagnosis Coding Guidelines

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There are cases where a diagnosis in the chart may not meet all the wiki criteria outlined for a specific code. Please consider the following points when trying to decide on the best way to code an unclear or difficult diagnosis.

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 judgement. Please see:

If the doctor says so, it probably is

  • If a doctor diagnoses a condition when our 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 pages. Examples include VAP and CLI.
    • Sometimes physicians and others might be using different criteria for diagnosing VAPs and CLIs, than the ones we have decided to use in our database. Collectors must follow our criteria to verify the presence of a VAP or CLI.

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

It is 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 with a strong medical knowledge base. This knowledge is necessary to interpret the chart and make reasonable coding decisions, especially when the diagnoses are ambiguous or unclear. If a good case can be made to defend coding an ambiguous diagnosis, then code it and vice versa.

Talk to the doctor

If you are unsure about a diagnosis, talk to the ward staff or the doctor. If there are any issues when you approach the staff with questions, please notify Trish.

Given that our data is largely collected retrospectively, it is less likely that there will be an opportunity talk to the staff, but at times this may be a reasonable approach to clarifying any patient information.

Related articles

Related articles:

[[Category: Data Collection Guide]]