Diagnosis Documentation : Morbidity & Mortality Dr. Muhammad Amirul Fakhri bin Mohd Nazri Ketua Penolong Pengarah (Perubatan) I Hospital Raja Perempuan Zainab II Kota Bharu, Kelantan Kementerian Kesihatan Malaysia (KKM)
Health Information Flow • History • Examinations • Investigations • Diagnosis formation • Plan & Management • Discharge Documentation in clinical case notes Documentation : • Diagnosis • Procedures PER-PD301 • Professionally trained coders in Medical Record Department • Coding based on : ✓ ICD-10 (diagnosis) ✓ ICD9-CM (procedures) Medical Records Department MyHDW
Borang Daftar Masuk dan Keluar Hospital (PER-PD 301)
P1 : Demographic details
P2 : Clinical diagnoses
P3 : Procedures & Verification
Diagnosis Documentation for Morbidity Cases
• ..as the condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation. • If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected. • If no diagnosis was made, the main symptom, abnormal finding or problem should be selected as the main condition.
The disease or injury which initiated the train of morbid events.
A disease that accompanies the main diagnosis and requires treatment and additional care, in addition to the treatment provided for the condition for which the patient was admitted.
A disease that appears during the episode of care, due to a pre-existing condition or arising as a result of the care received by the patient.
Document external causes of injuries/ accidents/ poisoning here
Elective Admission • Elective admission for ……………………… (specify reason/ investigation/ procedure/ treatment) as main diagnosis • Document the underlying condition as secondary diagnosis Example : ✓ Elective admission for physiotherapy (Z50.1) ✓ Elective admission for continuation of antibiotic (Z51.9)
Special Rules for Cancer Cases 1. If cancer is still present : Main diagnosis → Cancer Secondary diagnosis → Any treated complications, secondary or metastatic cancer or elective investigation/ procedure 2. If cancer has been removed : Main diagnosis → Any subsequent elective investigation/ procedure/ treatment Secondary diagnosis → Cancer post procedure 3. If cancer has been removed but patient is electively admitted for secondary/ metastatic cancer/ recurrence : Main diagnosis → Secondary/ metastatic cancer/ recurrence Secondary diagnosis → Elective investigation/ procedure/ treatment + history of primary cancer
Injury Cases Main diagnosis must include : • Type of injury → fracture/ dislocation/ wound • Site of injury • If fracture, to mention OPEN or CLOSED External cause of injury must include : Components Example • Patient’s mode of transport → Motorcycle, Car, Truck • Patient’s role → Driver or Passenger • Mechanism of injury → Collision with car, Skidded, Fall, Assault • Place of occurrence → Home, School, Workplace • Activity → While working, gardening, playing sport
Multiple conditions
Obstetric & Gynecology cases Antenatal Postnatal • Must specify gravidity and parity • Compulsory to state the period of gestation (POG) • Must specify the mode of delivery and complication of delivery (if any) • Compulsory to document the outcome of delivery Example : Gravida 2 Para 1 (G2P1) at 35 weeks of POG with threatened preterm labour Example : Spontaneous Vertex Delivery with first degree labial tear Outcome of delivery : Single live birth / Single stillbirth Twins live birth
Para 4 spontaneous vertex delivery with intact perineum Single live birth, baby boy with birth weight 3.1kg
Emergency Lower Segment Cesarean Section for breech presentation in labour Single live birth
Uncertain diagnosis If no definite diagnosis has been established by the end of an episode of care, then symptoms or abnormal findings must be recorded as main diagnosis. Examples : Patient came with fitting. Patient came with complaint of epigastric pain. Diagnosis : TRO epilepsy Correction → Fitting/seizure (R56.8) Diagnosis : Suspected peptic ulcer Correction → Epigastric pain (R10.1)
Elective admission for Angiogram Essential Hypertension Normal Angiogram finding
Write a complete diagnosis! Example → Diabetes Mellitus, must include : ✓ Type of DM : Insulin dependent or Non-insulin dependent ✓ Specify complications : - Coma (.0) - Peripheral circulatory complication (.5) - Ketoacidosis (.1) - Other specified complications (.6) - Renal (.2) - Multiple complications (.7) - Ophthalmic (.3) - Unspecified complications (.8) - Neurological(.4) - Without complication (.9)
Diagnosis Documentation for Mortality Cases
All those diseases, morbid conditions or injuries which either resulted in or contributed to death and the circumstances of the accident or violence which produced any such injuries (Column II) (a)The disease or injury which initiated the train of morbid events leading directly to death, or (b) the circumstances of the accident or violence which produced the fatal injury (Column III)
Used for diseases / causes related to the sequence / train of events leading directly to death Used for conditions that do not belong to the sequence but still contributed to death, i.e impairing patient’s general condition
Acute myocardial infarction Coronary artery thrombosis Atherosclerotic coronary artery disease
Acute myocardial infarction Coronary artery thrombosis Chronic ischemic heart disease 6 days 5 years 7 years
Acute respiratory acidosis Severe pneumonia COVID-19 category 5
Acute respiratory acidosis Severe pneumonia COVID-19 category 5 1 days 3 days 1 week Hypertension End stage renal failure
Procedures / Operation Documentation
What procedures NOT to document? ➢ Nursing routine procedures which – • Do not required special equipment • Do not required specialized staff Example : Dressing, vital signs recording, sponging, I/O charting, GCS charting, pain score charting ➢ Setting up peripheral arterial and venous line ➢ All blood investigations except Blood C&S
1. DISCHARGE WITH ORAL ACYCLOVIR (TOTAL 10/7), ANOTHER 5 DAYS 2. MDI SALBUTAMOL 4H X2/7, THEN 6H X2/7, THEN PRN BASIS 3. ADVICE OF NOT TO SEND PATIENT TO NURSERY YET, UNTIL THE LESION IS FULLY RESOLVED