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UHDDS Uniform Hospital Discharge Data Set is used for reporting inpatient data
UHDDS General terms are found in: General demographic information, expected payer, Hospital identification, principal diagnosis, other diagnoses that have specific significance, all significant procedures
The principal diagnosis treatments It is treated differently between outpatient and inpatient encounter
MS-DRG system Medicare severity-adjusted diagnosis-related groups system; a patient classification system used in hospital reimbursement
Other reportable diagnoses Conditions that coexist at the time of admission, develop subsequently, or affect patient care during the hospital stay
Principal diagnosis The condition established after study that is chiefly responsible for admission of the patient to the hospital
An example of Principal Diagnosis A pt adm with Urinary retention may prove to have hypertrophy of the prostate, which is causing the urinary retention. In this case, the prostatic hypertrophy is the principal diagnosis unless treatment was directed only to the urinary retention
Admission following medical observation A pt. may be treated in a hospital's observation unit to determine if the condition improves sufficiently for the patient to be discharged. If not improved, the principal diagnosis reported would be the medical condition that led to the hospital admission
Admission following postoperative observation A pt. undergoing outpatient surgery but require postoperative admission for observation
Admission from outpatient surgery A pt. undergoing outpatient surgery may be subsequently admitted for continuing inpatient care at the same hospital
Admission outpatient surgery guidelines If it is a compl, assign the compl. as the P diagnosis. If no compl then assign the reason for the outpt. surgery as the P. D. If the reason for the inpt. adm. is another cond. unrelated to the surgery then assign the unrelated condi. as the P diagnosis.
Created by: Lilyn Ta