My opinion - for discussion purposes.
Formerly, it was a matter of 'style' as to the utilization of 'assessment'. Most paper formats listed brief statements about the 'impression' of a diagnosis followed by a separate plan section that applied to all diagnoses in the visit. In the early days of EMR implementation, a decision was made to move from 'impressions' to 'assessments and plan' that permitted grouping of 'like items' under a single diagnosis. The CPOE form helped lead the change which has now become 'accepted format' for documentation in our EMR.
What we tend to forget is that we already struggle with 'repeat data' using this format (ie. a medication or order would ideally be present in two or more separate problem statements) and many resent the duplication in their notes.
Now we think we see a need to combine multiple diagnosis under one assessment, but I hope we can pause and see where this is not advantageous and could lead to unintended consequences.
To me, the logical and most practical choice is to return to the assessment as an impression and move the plan back to its own section with easy 'links' to associate a problem with it. Remember, under ICD10 a diagnosis is a diagnosis which deserves/requires documentation specific to it's own criteria, regardless of 'bundled or relational state'. Many codes are specific to the current 'status' of the condition making it extremely difficult to review 'trends' if they are combined, especially if the 'sub problems' are changed or removed (or new ones added) as care continues.
To put it into plain terms: ICD9 used 'combined codes' whereas ICD10 uses granular codes which in turn, require granular documentation. For example, high risk pregnancy was sufficient under ICD9 but translates to multiple codes under ICD10. The individual 'sub-problems' are prone to change in their own right, so it makes the best sense to document each individually so that the history can be seen a the granular level. To combine the assessments would be to resist the change imposed by ICD10 (resistance is futile) and most probably disadvantage the user in unforeseen ways in the future.
Again, just my thoughts to get a community discussion started on this new challenge. 🙂
Posted : October 28, 2015 4:25 am
