Wiki Admission and Discharge diagnosis

[pamfran]

We code admission diagnosis from admitting H & P and other hospital days pt has and discharge with diagnosis codes from discharge note. Is this what everyone else is doing? Thanks.

 

[LTibbetts]

I, personally, read over everything first so I have all of the information but the primary dx we use is usually coming from the discharge summary and the progress notes, whichever one deems to be what got the patient admitted in the first place and takes the most amount of care. The admit dx can come from the H&P but most of what the patient was treated for will be be on prog notes and d/s.

 

[donsqueen]

Our guidelines state that each note must stand alone. The one exception to that is on the discharge note, if a diagnosis was not dealt with sometime during the stay (including the discharge) we can leave it off (our doctors can add patient problem list to notes, which adds ALL diagnoses on the patient record).

This can cause some inconsistency for us, as one doctor may note diabetic ckd, and another may only note diabetes, and one could say type i and another type ii, etc. all in the same patient stay.