Diagnoses are reported based on the documentation of providers who deliver direct patient care.
- The attending provider’s documentation supersedes all other treating providers.
- Official Coding Guidelines state, “The listing of the diagnoses in the patient record is the responsibility of the attending provider.”
- The attending provider is defined by the UHDDS as the clinician of record at discharge who is responsible for the discharge summary.
Conflicting documentation must be clarified by the attending, likely resulting in a query.
- Incorporate the finding/diagnosis from consults and update the documentation to reflect the most relevant diagnosis or state the consultant’s diagnosis was ruled out to avoid queries.
- An example of conflicting documentation is when renal insufficiency is documented by the attending and acute renal failure by the nephrologist.
- Be sure to include the updated diagnosis in all future notes including the discharge summary.
Download the complete tip, Conflicting Documentation.