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preoperative diagnoses format - jt
Posted: Oct 29, 2010
I know when there are more than 1 diagnoses, you list each one separately. How do you handle it when the dictator gives 4 separate diagnoses, then "etiology to be determined" at the end? List everything under 1 dx, or list "etiology to be determined" as a separate dx?
Thanks.
a tough one... - nycmt
[ In Reply To ..]that's tough because he could mean the etiology is undetermined for the last diagnosis in the list...or he could mean the etiology is undetermined for all of the diagnoses. ugh.
was there a clear pause between the last diagnosis and the "etiology to be determined"? clear enough that you could assume he means it for all of the diagnoses? or was he quick about saying it right after the last diagnosis?
i would probably just make "etiology to be determined" the last diagnosis in the list, if it's not completely clear that he means to say that specifically for the last diagnosis in the list.
Judgement call, for sure. If he said "etiology to be -sm - Idle MT
[ In Reply To ..]determined" very close to the last sentence of diagnosis #4, I would put it there.
If it sounded like an entirely separate thought or sentence, I would put it as a separate sentence at the bottom of all 4 diagnoses, without a number, and the reader could associate it with whichever diagnosis he/she preferred, yet it would still be closest to the last Dx, "just in case".
;)
the four diagnoses and full context - might help
[ In Reply To ..].
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