Diagnosis Documentation Norms
Health encounters occur for a reason. Diagnosis documentation is about how responsible prescribers indicate the most responsible reason for the health encounter or the conclusion reached as a result of the encounter.
Encounter diagnoses may impact follow-up actions, after-visit summaries, enrolment in clinical investigations, inclusion in patient registries, content of analytics reports or initiation of chronic disease management plans.
Prescribers are responsible for selecting and recording one primary visit diagnosis (outpatient) or most responsible diagnosis (inpatient). This can be promoted from the Problem List as part of problem list reconciliation.