Awareness : OBC Tips

Hospital Admitting Diagnosis

The admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the patient’s provider who determined that inpatient care was necessary for treatment of a condition diagnosed that very day, or elective surgery, which was previously scheduled. This admission diagnosis (along with all other patient information) appears on the inpatient record face sheet. The admission diagnosis documented on the inpatient face sheet may differ from the admission diagnosis documented by the attending physician in the history and physical examination or admitting progress note. When different admitting diagnoses are documented in several places on the patient record:

Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet specifically.