Cardiology documented the following in a patient progress note on the second hospital day: “Troponins +, highest 6.4, needs cath STAT. + chest pain.” The chart has no further clarification, so what would be the principal diagnosis on discharge?
The prinicipal diagnosis would be “chest pain.” And you would need to send a query such as the following to the physician: “Acute myocardial infarction as cause of chest pain. Read cath lab note to further specify TYPE of MI if possible.”
This question was answered in the 2018 edition of 2018 Essentials for Clinical Documentation Integrity. For more hot topics relating to cardiology services, please view our store, or call us at 1.800.252.1578 ext. 2.