DIAGNOSIS

Abbreviation in diagnoses
• No abbreviation for diagnostic term in document section designating impression, admission diagnosis, discharge diagnosis, preoperative diagnosis, and postoperative diagnosis.
• Transcribed it as dictated if you cannot determine the meaning of a dictated abbreviation or acronym.
D: Operation. Left BK A T: Operation: Left below- knee amputation.
• Some descriptive terms rel to diagnosis may be abbreviated. Use abbreviation for units of measure.
Diagnosis: Laceration, 5 mm, Left abdomen.
Numbering diagnosis
• If plural form diagnoses if more than one listed. If one only diagnosis.
• It is preferable not to number one diagnosis even if a number is dictated. If there are several diagnoses, it is preferable to number them even if the numbers are not dictated.
E.g : DIAGNOSIS: Appendicitis
T: DIAGNOSES:
1. Appendicitis.
2. History of coronary artery bypass graft (CABG).
Psychiatric Diagnoses
• A multiaxial system is often used in diagnosis psychiatric patients:
Axis I: All psychiatric disorders.
Axis II: Personality disorders & Mental retardation.
Axis III: General medication condition.
Axis IV: Psychosocial and Environmental problems.
Axis V: Assessment of functioning, usually global assessment of functioning (GAF) scale.
• Dictated along w/ applicable diagnostic codes found in Diagnostic Statistical Manual of Mental Disorders
Axis I: 296.2 Major depressive disorder, single episode, severe without psychotic features.
305.0 Alcohol Abuse.
Axis II: 301.6 Dependent personality disorder.
Axis III: None.
Axis IV: Threat of job loss.
Axis V: GAF 53 (current)
Differential diagnosis
• When patient present w/in group of symptoms and diagnosis is unclear, the clinician may refer in medical report to the differential diagnosis in order to compare and contrast the clinical finding of each. Although it consists of two or more possible diagnoses, the term differential diagnosis takes a singular verb.
T: The differential diagnosis was….
“Same”
• Do not transcribed “same” when dictated for the discharge diagnosis - repeat diagnosis in full.
D: Admission diagnosis: Left testicular hernia.
Discharge diagnosis: Same.
T: ADMISSION DIAGNOSIS: Left testicular hernia.
DISCHARGE DIAGNOSIS: Left testicular hernia.
• Beware of similar incomplete statements w/in names of operations and transcribed them in full.
D: Operation performed : Repair of same.
T: OPERATION PERFORMED: Repair of left testicular hernia.