Wiki Different diagnoses - shift change

[MnTwins29]

Wondering what others do in this scenario: Dr. A sees an ED patient, works up the patient, renders a diagnosis and documents such in patient record. This is just before shift change, but the patient is not discharged or admitted, so the case is handed off to Dr. B, who reviews the record and comes up with a different diagnosis. Which one should be coded as the 1st listed diagnosis (assuming patient is not admitted)? Who would take precedence? And should both be coded?

 

[mitchellde]

I think it will depend on the diagnosis rendered by each and what made each provider decide on a different diagnosis.

 

[MnTwins29]

Maybe an example will help...pt presents with symptoms of SOB and cough. Worked up with CXR and EKG, both of which had no acute findings. Pt given Levaquin IVF. Dr. A, who was present for all these, had clinical impression of pneumonia (ordered the CXR with SOB, evaluate for PNA - no acute findings). After documenting this, but patient is not ready for discharge, Dr. B takes over case, documents review of exam, tests and medications - has clinical impression of bronchitis. We have discussed - split down the middle. Including myself - we vote 4-4 which one to use as first-listed.