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Documentation Tip of the Week: Principal Diagnosis

Posted on Thu, Jul 31, 2014

Principal Diagnosis 

Principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.


Remember: the diagnosis must be present on admission (POA) to be considered the principal diagnosis. Consider using possible/probable/likely or suspected diagnoses, for example if SIRS criteria are present on admission with a patient who has an infection, consider documenting “possible sepsis.” Remember to go back and clarify the next day.

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

 

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