diagnosis

[coffeekat]

why there is two diagnosis in the surgery summary sheet? one is the operative diagnosis : acute CVA and left lobar haemorrhage and the other is preoperative diagnosis : left haemorrhagic infarct and acute subdural haemorrhage

[Daytonite, BSN, RN]

I don't know. I've been studying coding of medical diagnoses for the past couple of years and this is one of the many aggravations that the medical record people have. Doctors can write the words of a medical diagnosis in many different ways. Basically, they all mean the same thing, although a CVA can be caused by either a hemorrhage or a blood clot that is blocking a vessel. While all four of those diagnoses are saying the patient had a stroke (CVA), only 3 of them are specifically saying it was due to hemorrhage and one specifically tells you that it was because of bleeding that occurred in the subdural space.

[queenjean]

When I see the operative summaries at our hospital, there are two diagnoses, one is the preop diagnosis, one is the postop diagnosis. I think it is pretty simple--once they actually get in there, the diagnosis may change. For example: preop diagnosis is suspected appendicitis. Postop diagnosis may be something like: ruptured appendix, peritonitis.

That's how I've always read the summaries, anyhow.