Primary Admit Diagnosis

The Primary Admit Dx (Most Responsible Diagnosis, MRDx) is the dx most responsible for an admission to that unit/ward. See Dx Primary for details on how it is entered into the collection tool.

• When there are multiple competing diagnoses, choose the one that is the most severe or responsible for the admission. At times this may be difficult to determine, use your best clinical judgment based on the documentation.

Example:

Admitted with: Pneumonia, NOS which is noted to be not severe, and CVA which is severe Primary Reason to be checked off: CVA.

• If multiple trauma is the main reason for admission there will be a group of linked ICD10 codes that make up the Admit Diagnosis; the Primary Admit Diagnosis would be either the Multiple trauma or the "worst" thing injured, e.g. Brain injury, diffuse (TBI), injury/trauma
• For a patient admitted after a procedure, for a routine procedure without complications chose the diagnosis that required the procedure; if complications after the procedure were the reasons for admission then code those.

Example:

elective CABG to ICCS if routine with no complications primary would be Coronary artery disease, chronic, if elective but on pressors for a few hours , but no Shock, cardiogenic link the Iatrogenic, hypotension/shock, postoperative/post-procedural with Coronary artery disease, chronic and check the Iatrogenic, hypotension/shock, postoperative/post-procedural as primary, if elective CABG but are unstable post op and meet the criteria for Shock, cardiogenic then link this diagnosis with Coronary artery disease, chronic and Iatrogenic, hypotension/shock, postoperative/post-procedural and check the cardiogenic shock as the primary diagnosis.

Data use

The concept is used by the following indicators:

• ICU Primary Diagnosis ICD10 Chapter Rate
• ICU Diagnosis APACHE Category Rate
• Medicine Primary Diagnosis Rate

Cross checks

See Dx Primary#Data Integrity Checks (SMW)

Related queries

• Query L_Dxs_w_primary
• Query L_ICD10_primary

Legacy info

Legacy info

Old dx schema Admit Diagnosis with highest priority