Wiki Hospital Discharge diagnosis

[tfennell]

I am a student and have a question on hospital discharge summaries. Some list discharge diagnosis but some have multiple diagnosis under the heading Impressions. Are these supposed to be coded as discharge diagnosis? I would appreciate hearing from someone who knows the answer. Thanks!

 

[aroden]

Yes, Code the diagnoses that are pertinent to the patient and relevant to the stay. Check your inpatient coding guidelines for secondary diagnoses coding and also the facility policy. For the most part if attention was paid to the dx and medications were administered.

 

[tfennell]

Thank you. Some were long and seemed a little ambiguous. I appreciate your help.