Rules & Key Elements for Each Section Principal Diagnosis (PD) Linked Cause (If Applicable) Secondary Diagnoses Procedures Specificity Requirements (These add coding weight, so missing detail costs money.) Clinical Significance of Abnormal Tests
Section Key Requirements for Coding Principal Diagnosis (PD) ONE condition per admissionMost serious or resource-heavyState clearly in summaryIf uncertain: use probable/likely Secondary Diagnoses Include any condition that:→ Requires treatment, monitoring, or tests→ Increases complexity/resources– Link cause and effect (e.g., Anaemia…
Date implemented – 05/2017Review date – nil plannedAuthor – Nuria O’Mahony / Mike Cadogan
Date implemented – 01/2020Review date – nil plannedAuthor – Lynette White (NP), Dr Antony Clark (Ophthamology), Dr Jehan De Souyza (Ophthamology)
Here will be the roster for the Registrar WBA and Consultant Clinical Teaching sessions when it is done – until then refer to the daily running sheets for the consultant assigned to Clinical Teaching…
