Author Question: Distinguish between the terms principal diagnosis and secondary ... (Read 63 times)

crazycityslicker · **on:** Jul 12, 2018

Distinguish between the terms principal diagnosis and secondary diagnoses.

Question 2

Sally Jones is a 74-year-old inpatient at Sunny View Hospital. During the night her temperature rose, and she is currently not responding to the nurses. Nurse Smith informed the attending physician and called the family. Discuss the information that should be recorded in a progress note.

jomama · **Reply #1 on:** Jul 12, 2018

Answer to Question 1

Principal diagnosis is the condition established, after study, to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Secondary diagnoses are additional conditions for which the patient received treatment or which impacted inpatient care.

Answer to Question 2

Since Sally's condition has changed, documentation in the patient record must reflect this; documentation should also reflect follow-up measures taken by the staff. The call to the attending physician should also be noted. Since Nurse Smith called the family, she should document the time of call and to whom she spoke, as well as the information given to the family.