Identifying and definitional attributes | |
Metadata item type: | Data Element |
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Short name: | Principal diagnosis |
METEOR identifier: | 746665 |
Registration status: | Health!, Standard 20/10/2021 |
Definition: | The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment, as represented by a code. |
Data Element Concept: | Episode of care—principal diagnosis |
Value Domain: | Diagnosis code (ICD-10-AM 12th edn) ANN{.N[N]} |
Value domain attributes | ||
Representational attributes | ||
Classification scheme: | International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification 12th edition | |
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Representation class: | Code | |
Data type: | String | |
Format: | ANN{.N[N]} | |
Maximum character length: | 6 |
Source and reference attributes | |
Origin: | Independent Hospital Pricing Authority |
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Data element attributes | |
Collection and usage attributes | |
Guide for use: | The principal diagnosis must be determined in accordance with the Australian Coding Standards (IHPA, 2022). Each episode of admitted patient care must have a principal diagnosis and may have additional diagnoses. The diagnosis can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status. As a minimum requirement the Principal diagnosis code must be a valid code from the current edition of the International statistical classification of diseases and related health problems, Tenth Revision, Australian Modification (ICD-10-AM). Diagnosis codes starting with a V, W, X or Y, describing the circumstances that cause an injury, rather than the nature of the injury, cannot be used as a principal diagnosis. Diagnosis codes which are morphology codes cannot be used as a principal diagnosis. |
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Collection methods: | A principal diagnosis should be recorded and coded upon separation, for each episode of admitted patient care or episode of residential care or attendance at a health-care establishment. The principal diagnosis is derived from and must be substantiated by clinical documentation. |
Comments: | The principal diagnosis is one of the most valuable health data elements. It is used for epidemiological research, casemix studies and planning purposes. |
Source and reference attributes | |
Origin: | Independent Hospital Pricing Authority |
Reference documents: | IHPA (Independent Hospital Pricing Authority) 2022. Australian Coding Standards Twelfth Edition. Sydney: IHPA. |
Relational attributes | |
Related metadata references: | Supersedes Episode of care—principal diagnosis, code (ICD-10-AM 11th edn) ANN{.N[N]} Health!, Superseded 20/10/2021 Tasmanian Health, Standard 08/04/2019 See also Episode of care—additional diagnosis, code (ICD-10-AM 12th edn) ANN{.N[N]} Health!, Standard 20/10/2021 |
Implementation in Data Set Specifications: | Activity based funding: Mental health care NBEDS 2022–23 Health!, Standard 17/12/2021 Implementation start date: 01/07/2022 Implementation end date: 30/06/2023 Admitted patient care NMDS 2022–23 Health!, Standard 20/10/2021 Implementation start date: 01/07/2022 Implementation end date: 30/06/2023 DSS specific information: The principal diagnosis is a major determinant in the classification of Australian Refined Diagnosis Related Groups and Major Diagnostic Categories. Where the principal diagnosis is recorded prior to discharge (as in the annual census of public psychiatric hospital patients), it is the current provisional principal diagnosis. Only use the admission diagnosis when no other diagnostic information is available. The current provisional diagnosis may be the same as the admission diagnosis. Community mental health care NMDS 2022–23 Health!, Standard 17/12/2021 Implementation start date: 01/07/2022 Implementation end date: 30/06/2023 Residential mental health care NMDS 2022–23 Health!, Standard 17/12/2021 Implementation start date: 01/07/2022 Implementation end date: 30/06/2023 DSS specific information: Codes can be used from ICD-10-AM or from The ICD-10-AM Mental Health Manual: An Integrated Classification and Diagnostic Tool for Community-Based Mental Health Services, published by the National Centre for Classification in Health 2002. The principal diagnosis should be recorded and coded upon the end of an episode of residential care (i.e. annually for continuing residential care). |