Hoosierdaddy

Member
10+ Year Member
15+ Year Member
Aug 29, 2001
56
1
Indiana
Status (Visible)
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

Quantum Member
15+ Year Member
Jul 25, 2003
1,614
6
42
Winston Salem, NC
Status (Visible)
  1. Attending Physician
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

My name is Neo
Moderator Emeritus
10+ Year Member
15+ Year Member
Dec 6, 2000
4,227
16
Wisconsin
Status (Visible)
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
 
About the Ads

Seaglass

Quantum Member
15+ Year Member
Jul 25, 2003
1,614
6
42
Winston Salem, NC
Status (Visible)
  1. Attending Physician
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 :)
 

IndyXRT

Full Member
10+ Year Member
15+ Year Member
Mar 17, 2004
450
1
Status (Visible)
  1. Attending Physician
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

stargazer
7+ Year Member
15+ Year Member
Feb 23, 2003
2,809
1
42
soon to be Winston-Salem
Status (Visible)
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

Full Member
10+ Year Member
15+ Year Member
Mar 17, 2004
450
1
Status (Visible)
  1. Attending Physician
Yes, the phrase "patient denies alcohol use" tends to leave one with less egg on one's face. . .
 
About the Ads
This thread is more than 17 years old.

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.