Thursday, November 17, 2016

Principal Diagnoses - TIPS

Pdx: Two or More Diagnoses - Tips

Present on admission does not equal reason for admission

Look at what condition appears to be most closely related to the signs, symptoms and other findings that were noted on admission

Reason for presentation to the Emergency Department is not always the reason for inpatient admission

One condition may have necessitated inpatient admission, while the other may have been manageable in the outpatient setting

Chronic conditions and/or acute conditions, may be incidental to the reason for admission
These should not be reported as principal diagnosis

For patients transferred into our facilities, be sure to identify the reason for the transfer
Usually, it is due to the fact that the level of service needed by the patient could not be performed at the originating facility


Objectively evaluate the circumstances of admission and sequence accordingly.

Review physician’s workup and treatment provided – it may be that the two conditions are not as equal as they initially appeared. 

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