Recording diagnoses in the CMI/ODS assists in the clinical management of the person, and provides essential information to the department to develop policies and priorities for resource allocation.
It is also a mandatory data element in national minimum datasets.
There are three classes of diagnosis available in CMI/ODS:
- an admission diagnosis, for all non-acute and residential episodes of care
- a separation diagnosis, for all admitted, non-acute and residential episodes of care
- a community diagnosis, for all community clients.
Definition of a diagnosis
A diagnosis is the decision reached, after assessment, of the nature and identity of the disease or condition of a patient.
It represents the major or principal condition and other primary conditions, complications or comorbidities and associated conditions treated or investigated during the relevant episode of care.
Diagnoses must be coded in accordance with the Victorian additions to the Australian coding standards and the department’s ICD: clinical coding information.
Every admitted episode of care must have a separation diagnosis assigned within six months of separation.
This is in line with the Victorian Admitted Episodes Dataset (VAED) reporting requirements for admitted episodes, and will assist health services to comply with the reporting requirements of both systems.
Services may need to record diagnoses earlier to analyse their outcome measurement data.
For a same-day ECT procedure ‘Task‘ event, record a separation diagnosis for each course of treatment, using the diagnosis associated with the reason for ECT, as specified by the treating psychiatrist on the consent form.
Non-acute and residential
Separation diagnosis must be entered in the same way as acute inpatient services.
Non-acute and residential admitted episodes must also be assigned an admission diagnosis.
These episodes of care must have an admission diagnosis assigned within six weeks of the end of the month of admission (for episodes of less than one month the separation diagnosis is sufficient).
Registered community clients who do not have a case or episode must have a community event diagnosis recorded within four weeks of the end of the month in which the episode started.
Ongoing community episodes must have that diagnosis reviewed and updated at intervals of no more than 12 months.
If the final diagnosis is from a bed-based service, enter the diagnosis as outlined above.
A diagnosis is required to finalise the episode of care (case closure). If this is a community episode the diagnosis must be entered within four weeks of the end of the month of the episode’s end.
If the final episode is from a bed-based service, enter the diagnosis as outlined above.