Documentation Tip

Definitive vs. Descriptive Diagnoses

Documentation Tip: Definitive vs. Descriptive Diagnoses

Definitive diagnoses are the conclusions to the clinical findings of the physician and are used to develop the treatment plan and to justify the treatment rendered. Definitive diagnoses are stated in terms acceptable to care-givers, hospital medical records and hospital billing requirements. These commonly obscure the real reasons the patient sought treatment and the level of complexity of the care received.

Descriptive diagnoses are the descriptions of the patient’s presenting signs and symptoms and/or conclusive clinical findings that are coded in ICD-10 CM language to substantiate the need for urgent, unscheduled medical care in the Emergency Department. Descriptive diagnoses are stated in terms that better describe the reasons for treatment, the level of care delivered and are often better understood by third party payers.

Key Phrases To Describe The Patient’s Condition

  • Acute
  • Pain
  • Distress
  • Severe
  • Threatened
  • Traumatic
  • Sudden
  • Serious
  • Febrile

Emergency physicians often do not render an actual “final” diagnosis since many ED cases require further work-up by other medical specialists to determine the patient’s true condition. ED charts should reflect the ED physician’s “Clinical Impression”, rather than the “Final Diagnosis”.

Conclusive Findings

  • Chronic Asthma
  • Asthma
  • Chronic back strain
  • Cephalgia
  • Esophagitis

Descriptive Findings

  • Respiratory distress
  • Acute dyspnea
  • Acute lumbosacral strain
  • Acute migraine headache
  • Chest pain

Whenever possible, include descriptive phrases in your clinical impression, as well as in your HPI.

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