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Discharge summaries

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Hoosierdaddy

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Maybe you guys can shed some light on a question I've had for a while now:

When you are doing the discharge summary on a patient with multiple medical problems that were diagnosed at some time in the past (CAD, COPD, BPH, GERD, etc.), what do you list under the heading "Admission Diagnosis?" Do you list only the one or two diagnoses that led to the admission, or do you list all of the patient's diagnoses, even if they are unrelated to the reason the patient was admitted? Let me know what you guys think.
 

Seaglass

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under "Admission Diagoses" I usually list the diagnosis/ses for which they were admitted. I always put other chronic illnesses under PMH. So, for DM, I would list DKA as the admisison Dx and Type1/2 DM under the history.

C
 

DrQuinn

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Some people list as many diagnoses that they can...

Like for DKA:

Hyperglycemia
Diabetic Ketoacidosis
Hypokalemia
Abdominal Pain
Vomiting

Some people don't subscribe to that thinking.

Q, DO
 

Seaglass

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I think that people who do that are trying to maximize their billing - i.e. list everything and let the billing people sort through what is actually billable. Unfortunately you can usually only use the best ICD-9 code that describes the condition, unless the conditions are truly separate. At least that's how it was explained to me by a billing specialist.

C
 
N

njbmd

Hi there,
I list the "primary diagnosis" (the condition that the patent was admitted for) and other conditions under "secondary diagnoses".
This can keep you out of trouble in most cases.

njbmd :)
 

Seaglass

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Yeah, that's a good strategy. I will adopt it post-haste.

C
 

Hoosierdaddy

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Yeah, that's a good idea. I think I'll start doing that as well. Thanks.
 

IndyXRT

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When you are doing the discharge summary on a patient with multiple medical problems that were diagnosed at some time in the past (CAD, COPD, BPH, GERD, etc.), what do you list under the heading "Admission Diagnosis?"

I agree with listing primary and secondary admission diagnoses. However, I want to point out that conditions diagnosed in the past (as referred to in the origional post, quoted above) that did not directly contribute to the current admission should not be listed as admission diagnoses in any form. Using the DKA example, if your patient with DKA also had CAD, you would not list CAD as an admission diagnosis.
 

gwyn779

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Speaking of discharge summaries, I got to do a consult on a patient in alcohol withdrawal today who'd already had a discharge summary in the computer for yesterday. What's even better is that under social history it said "no alcohol use."
 

IndyXRT

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Yes, the phrase "patient denies alcohol use" tends to leave one with less egg on one's face. . .
 
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