Diagnosis

Introduction

The Diagnosis data model is an integral part of healthcare information systems, designed to capture and manage essential information related to patient diagnoses. It is primarily used to convey diagnosis information at various stages of a patient's healthcare journey, enabling healthcare providers to accurately document, track, and communicate diagnoses. This model plays a crucial role in supporting clinical decision-making, treatment planning, billing, and quality assessment in healthcare settings.

Use Case

Developers can harness the capabilities of the Diagnosis data model to support a wide range of technical use cases, facilitating efficient management of diagnosis-related information and enhancing the overall quality of patient care:

Diagnosis Documentation: Developers can create applications that allow healthcare professionals to document patient diagnoses systematically. This ensures that all relevant diagnosis details are captured accurately and consistently.
Diagnosis Retrieval: Developers can build systems that enable users to retrieve diagnosis information efficiently. Healthcare providers can access a patient's complete diagnosis history, aiding in clinical assessments and treatment planning.
Treatment Planning: Developers can integrate diagnosis data into treatment planning tools. This enables healthcare teams to make informed decisions about patient care based on the diagnosed conditions and their severity.
Billing and Coding: Healthcare facilities rely on accurate diagnosis information for billing and coding purposes¹. Developers can create systems that automatically assign appropriate diagnosis codes based on clinical documentation, streamlining the billing process.
Clinical Decision Support: Developers can integrate diagnosis data into clinical decision support systems. These systems can provide alerts, reminders, and recommendations to healthcare providers based on diagnosed conditions, ensuring evidence-based care.
Quality Assessment: Healthcare organizations often use diagnosis data to assess the quality of care provided. Developers can design reporting tools that analyze diagnosis patterns and outcomes to identify areas for improvement.
Patient Education: Developers can create patient-facing applications that provide patients with information about their diagnosed conditions. This empowers patients to understand their health status and treatment options.
Research and Analytics: Diagnosis data can be a valuable resource for medical research and analytics. Developers can build platforms for researchers to access

Data Fields

Attribute Name	Description	HL7 Mapping	Data Type	Label	Use Case
drg_approval_indicator	Drg Approval Indicator	DG1-9	string	Drg Approval Indicator	Diagnosis-Related Groups (DRGs) are a classification system used for grouping patients with similar clinical conditions for billing and reimbursement purposes. This is used to indicate whether the DRG assignment for a specific patient's case has been approved by the healthcare facility or payer.
batch_id	Batch id	System Generated	string	Batch ID	"batch ID" is a unique identifier assigned to a group of messages that are logically grouped together for processing or transmission. Batching messages is a common practice in healthcare systems to efficiently manage and transmit multiple messages as a single unit
bundle_id	ID of bundle	MSH-10	string	Bundle ID	“bundle ID" typically refers to a unique identifier assigned to a group or bundle of related messages or data elements. This identifier is used to associate multiple messages or pieces of information that are related to a specific patient, event, or transaction.
encounter_id	Encounter ID	PV1+MSH-10	string	Encounter ID	This unique identifier is used to associate various HL7 messages with a specific patient encounter or visit. It ensures that data and events are accurately linked to the correct patient's healthcare journey.
outlier_days	Outlier Days	DG1-12	string	Outlier Days	This field contains a numerical value that represents the number of days by which a patient's hospital stay exceeds the standard length of stay for the assigned DRG. It indicates that the patient's condition or treatment required an extended duration of care beyond what is typically expected for that DRG.
diagnosis_type	Diagnosis Type	DG1-6	string	Diagnosis Type	This field can indicate whether a diagnosis is the principal diagnosis, which is the primary reason for the patient's hospitalisation. Accurately identifying the principal diagnosis is crucial for proper billing, resource allocation, and clinical decision-making.
outlier_cost	Outlier Cost	DG1-13	string	Outlier Cost	The Outlier Cost field helps identify cases where the cost of care deviates significantly from the expected cost for a specific DRG. These cases are referred to as "outliers."
attestation_datetime	Attestation Datetime	DG1-19	date	Attestation Datetime	This field contains a timestamp, typically in the format of YYYYMMDDHHMMSS (Year, Month, Day, Hour, Minute, Second). It represents the date and time when a healthcare provider or clinician formally attests to the accuracy and completeness of a specific diagnosis or clinical information.
confidential_indicator	Confidential Indicator	DG1-18	string	Confidential Indicator	The Confidential Indicator helps ensure that sensitive clinical information, such as psychiatric diagnoses or sexually transmitted diseases, is appropriately marked as confidential to protect patient privacy.
diagnosis_description	Diagnosis Description	DG1-4	string	Diagnosis Description	The Diagnosis Description field is essential for clear communication between healthcare providers, patients, and other healthcare professionals. It conveys the diagnosis in plain language that can be easily understood by individuals who may not be familiar with medical coding.
diagnosis_action_code	Diagnosis Action Code	DG1-21	string	Diagnosis Action Code	The Diagnosis Action Code is crucial for managing and tracking changes to a patient's diagnosis over time. It helps healthcare providers and systems distinguish between new diagnoses, updates to existing diagnoses, and deletions.
visit_number	Id of the visit	PV1-19-1	string	Visit Number	The visit number serves as a unique identifier for a specific patient visit or encounter within a healthcare facility. It distinguishes one visit from another.
diagnostic_category	Diagnostic Category	DG1-7	string	Diagnostic Category	The Diagnosis Category field provides additional information about the type or category of diagnosis associated with a patient's condition. It helps classify diagnoses into broader categories for various purposes, including reporting, billing, and statistical analysis.
diagnosis_classification	Diagnosis Classification	DG1-17	string	Diagnosis Classification	The Diagnosis Classification field provides additional information about how a diagnosis has been classified or categorised within a specific coding system or classification scheme.
diagnostic_related_group	Diagnostic Related Group	DG1-8	string	Diagnostic Related Group	This field contains the code or identifier that corresponds to the specific DRG assignment for a patient's diagnosis and treatment. The DRG code reflects the expected resource utilisation and cost associated with a patient's condition.
drg_grouper_review_code	Drg Grouper Review Code	DG1-10	string	Drg Grouper Review Code	This field contains a code or value that indicates the status or outcome of the DRG grouping review process for the diagnosis. DRGs are a classification system used for grouping patients with similar clinical conditions and treatment costs for billing and reimbursement purposes.
alternate_visit_id	Alternative visit id	PV1-50/PID-18	string	Alternate Visit Id	This field provides an alternate identifier for a patient's visit. It is used for tracking and cross-referencing patient visits and records, especially in scenarios requiring multiple identifiers or references. This field is recorded during patient registration and aids in accurate record linkage.
diagnosis_coding_method	Diagnosis Coding Method	DG1-2	string	Diagnosis Coding Method	This field helps in explaining why a particular DRG code was assigned to a patient. It may specify factors or criteria that influenced the DRG classification, such as the complexity of the case, the presence of complications or comorbidities, or other clinical considerations
diagnosis_datetime	Diagnosis Datetime	DG1-5	date	Diagnosis Datetime	The Diagnosis Date/Time is crucial for establishing a chronological record of a patient's medical history. It helps healthcare providers and clinicians understand when a specific condition or diagnosis was identified in relation to the patient's overall medical timeline.
diagnosis_code	Diagnosis Code	DG1-3	string	Diagnosis Code	Diagnosis codes provide a standardised way to represent medical conditions. This standardisation ensures that healthcare providers and organisations use a common language for describing diagnoses, facilitating accurate communication and record-keeping.
patient_id	Id of the patient	PID-3-1	string	Patient ID	The patient ID is a unique identifier assigned to a patient within the healthcare system. It is used to accurately identify and link a patient's medical records, treatments, and history.
xc_visit_id	XC visit id	Based on alternate_visit_id followed by visit_number followed by system generated ID	string	XC visit id	The "xc_visit_id" is a unique identifier used to group together all the interactions, procedures, tests, and check-ups associated with a single patient visit in a healthcare setting. This identifier helps in organising and managing various activities and data related to that specific patient encounter.
lineage	This is lineage attribute	Fixed - HL7	string	Lineage	"lineage" refers to the information about the origin or source of a message. It helps trace the path of the message, indicating where it originated, how it was transmitted, and any intermediate systems or components it passed through before reaching its destination.
diagnosis_id	Id of diagnosis	DG1+MSH-10	string	Diagnosis ID	This field contains the code that represents a specific medical diagnosis or condition, often based on a standardised coding system like ICD-10.
outlier_type	Outlier Type	DG1-11	string	Outlier Type	This field specifies the type of outlier for a particular diagnosis-related group (DRG) assignment. It provides information about the reason why a specific case is considered an outlier in the DRG-based reimbursement system.
grouper_version_type	Grouper Version Type	DG1-14	string	Grouper Version Type	This field provides information about the specific version and type of the DRG grouper system that was used to classify and group the patient's diagnosis.
diagnosis_priority	Diagnosis Priority	DG1-15	string	Diagnosis Priority	Diagnosis can vary in terms of their urgency and impact on the patient's treatment plan. The diagnosis priority field helps clinicians and care teams prioritise which diagnoses require immediate attention or intervention.

Similar Models

Here are the models that are similar to the current data model

Diagnosis_Identifier - It captures and gives information regarding the patient's diagnosis and their handling by providers

Diagnosis_Provider - It captures and gives information regarding the patient's diagnosis and their handling by providers

Allergy

Diagnosis Identifier