Skilled Nursing Facilities

Contents

Medical Diagnosis - Rank and Classification Overview

When you are entering a new Medical Diagnosis, you may see fields for Rank and Classification. It is important to understand what each of these terms means and to understand how the PointClickCare application handles each of these.

  1. Rank

    • Designates diagnoses as Primary, Secondary and so on.

    • Current Template is set up to accommodate two Ranks: Principal and Other.

    • Principal

      • Designates the primary condition for which a resident is being treated at the facility.

      • Only one diagnosis can be designated as the principal diagnosis.

      • The principal diagnosis always appears first in the medical diagnosis listing.

    • 'Other'

      • Designates all other conditions for which the resident is being treated or monitored.

      • These populate fields A-X of the UB-04.

      • If more than 24 diagnoses are designated as 'Other', the most recent 24 flows to the UB-04 fields A-X.

      • Other diagnosis appear on the diagnosis list with the most recently added appearing just after the principal.

    • Additionally, depending upon configuration, rank may dictate the order in which the rest of the diagnoses appear in the medical diagnosis list as well as on the UB-04. For example, configuring rank so that after principal diagnosis there are additional: Diagnosis 2, Diagnosis 3, Diagnosis 4 and so on, each allowing only one diagnosis per rank allows you to dictate the order. For more information see Configuration Instructions.

    • The diagnosis rank should be re-evaluated as the resident's condition changes. For example as a resident moves from skilled care or as acute conditions resolve

  2. Classification

    • Diagnosis Classification allows you to configure the system to track conditions according to any categorizations which are important to your organization. For example, our template classifications allow you to use Diagnosis Classification to track the origin of a condition's onset in a Resident by specifying:

      • Admitting to indicate the primary diagnosis that caused the resident to be admitted to the facility.

        • This is often, but not always, the same as the Principal diagnosis.

        • The diagnosis classified as Admitting flows to field #69 of the UB-04.

        • Only one diagnosis may be classified as admitting.

        • Unlike rank, the Admitting diagnosis should not change unless the resident is discharged and admitted again at a later time.

    • Admission to indicate any active diagnoses at the time of admission.

    • Discharge to indicate an onset at the time of, or reason for discharge.

    • During Stay to indicate an onset while in your organization's care

    • History to indicate an onset before admission.

Note

A diagnosis noted as 'history' still flows to the ub-04 and MDS unless a 'resolved' date is entered for that diagnosis. Simply classifying the diagnosis as history does not cause the system to treat that diagnosis any differently.