RE: [EXTERNAL] RE: Principal Dx
That’s what I was thinking too Sharon.
The hematoma seems to be a secondary diagnosis based on what was presented, but again the why the patient was admitted needs to be clarified. If it is to treat the pneumonia and supportive care only for the subdural hematoma, pneumonia would be principal. It is after all the “reason after study that precipitates the admission” which is principal, not necessarily the admitting diagnosis.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
The hematoma seems to be a secondary diagnosis based on what was presented, but again the why the patient was admitted needs to be clarified. If it is to treat the pneumonia and supportive care only for the subdural hematoma, pneumonia would be principal. It is after all the “reason after study that precipitates the admission” which is principal, not necessarily the admitting diagnosis.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens