IMPROVING THE DOCUMENTATION OF DIAGNOSES Carol A. Lewis

Reasons for interest USA –Medical severity DRGs (MS-DRG) –Present on admission (POA) –Insurance fraud and abuse Latin America and Caribbean –Vital and health statistics –Data for planning, management, and evaluation

Definition of diagnosis 1.The term which denotes the disease from which a patient suffers, e.g., pulmonary tuberculosis, measles, cerebral thrombosis; such labels are useful for certificates, vital statistics and hospital records. Source: Butterworths Medical Dictionary

Definition of diagnosis 2. The art of applying scientific methods to the elucidation of the problems presented by a sick patient. This implies the collection and critical evaluation of all the evidence obtained from every possible source and by the use of any method necessary. From the facts...

Definition of diagnosis (Cont.) From the facts so obtained, combined with a knowledge of basic principles, a concept is formed of the aetiology, pathological lesions and disordered functions which constitute the patient’s disease. This may enable the disease to be placed in a certain recognized category but, of far more importance, it also provides a sure basis for the treatment and prognosis of the individual patient.

Alvan Feinstein on diagnosis Diagnosis is the focal point of thought in the treatment of a patient Diagnostic labels transmit a rapid understanding of the package Diagnostic categories provide names for the intellectual locations in which clinicians store observations of clinical experience

Diagnosis is based on data Laboratory investigations, X-ray examinations, clinical tracings Doctor skilled in taking a history and performing a physical examination Coordinate findings Physician’s primary job is to discover what ails the patient, not merely to diagnose disease

Important role of documentation Description – Physician relates what he has observed Designation – gives a name or classification to the entity observed Diagnosis – indicates the anatomic or other abnormality responsible for the observed entity

Symptoms and most signs, permanent evidence is the descriptive information entered in medical record Only the physician treating the patient can confirm if admitting and preliminary diagnoses still apply at time of discharge Physician should write final diagnoses on front sheet of the record.

Documentation relating to diagnoses The diagnosis or diagnoses which were established The facts on which the diagnosis was based.

Communication Admitting diagnosis – “Hypertension” Discharge diagnosis – “↑ B.P.” How should this be interpreted?

Concerns about diagnoses No diagnosis Doesn’t explain reason for admission Expressed as procedure “hernia repair”, “L.S.C.S” No indication of severity Significant complications and co- morbidities not indicated Not supported by documentation in record

Why should we be concerned? Wasteful of staff time to read entire record Records will not be retrieved for study Statistics that rely on coded data will be adversely affected Trend analysis made difficult

What I’ve learned Be specific about problems and quantify them Do doctor’s concur about problems and what do they see as obstacles to recording complete and accurate diagnoses? Written guidelines are useful in establishing and communicating policies Personal communication is important

Let’s exchange experiences!