Coding from Diagnosis List

jackietouch@aol.com

I have reviewed previous threads for this topic, but could only find discussions related to problem lists, so here goes...

Our diagnosis list (Cerner) populates based on IMO terminology with an "annotated display" and a "clinical diagnosis display". Often, the annotated display is abbreviated, lacking specificity that is found in the clinical diagnosis display.

My feeling is that the diagnosis list is being managed for the specific, current encounter and therefore, as part of the medical record, can be utilized in its entirety for coding purposes/obtaining specificity. Coders generally will not code from the clinical diagnosis list because only the annotated display terminology populates the progress notes.

Any thoughts/insights/wisdom on this topic are greatly appreciated!!

Thanks in advance,
Jackie Touch, MSN, RN, CCM
Clinical Documentation Specialist
CHOC Children's

jackietouch@aol.com

Thank you for weighing in on this one, Dr. G. Wouldn't it be great if the IT world and HIM world could collaborate to make things just a wee bit more efficient? I find myself spending a good chunk of time trying to figure out ways to streamline things for the MDs by utilizing available tools (ie diagnosis lists) just to find that those said tools do not fully meet the needs of either clinicians or coders/CDI staff.

Off my soapbox now...thanks for letting me vent.

Jackie