Diagnoses and the problem list
The difference between a diagnosis on today's note and a problem that follows the patient, and how to use ICD-10 without fighting it.
2 min read
These are two different things and it is worth being clear about which you are recording.
A diagnosis belongs to one consultation. It is what you concluded today.
A problem follows the patient. Diabetes, hypertension, sickle cell disease, a pregnancy — things that are true of the person between visits and that the next clinician needs to know without reading every past note.
A diagnosis can become a problem. Malaria today is a diagnosis and not a problem; newly diagnosed hypertension is both.
Using ICD-10
Search by name or by code. Typing "malaria" finds the malaria codes; typing "B50" finds them too.
Three practical notes:
Take the nearest code and write what you mean. ICD-10 was not written for a Nigerian general outpatient clinic and sometimes nothing fits. The nearest code plus a clear line of free text is better than an hour of hunting, and far better than no code at all.
"Unspecified" is a real answer. Codes ending in .9 exist for exactly the
case where you know the condition and not the detail.
Do not code what you are ruling out. A coded diagnosis reads as "this patient had this". Suspicions belong in the assessment.
The problem list
Add beside Active Problems on the clinical summary. A problem stays until somebody marks it resolved, and resolving it does not erase it — it stays in the history with the date.
Keep it short. A problem list of twenty entries is read by nobody, which defeats its only purpose.
Where this ends up
Coded diagnoses are what the hospital's clinical reporting is made of, what an HMO or NHIA claim is built on, and what statutory returns need. Nobody retypes them from your notes later, and nobody can: if it was not coded at the consultation, it is not in the figures.