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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.
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.