Recording diagnoses in CMI/ODS - October 2006 (Program management circular)

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Purpose

To provide advice about when to record diagnoses in CMI/ODS for persons receiving treatment in public mental health services.

Key message

An admission (1) diagnosis is required for all non-acute and residential episodes of care.

A separation (1) diagnosis is required for all admitted, non-acute and residential episodes of care.

A community (1) diagnosis is required for all community clients.

Background

CMI/ODS is the Victorian public mental health client information management system and comprises:

• Client Management Interface (CMI). The CMI is the local client information system used by each public mental health service
• Operational Data Store (ODS). The ODS manages a set of select data items from each CMI. The ODS is used to:
  • allocate a unique (mental health) registration number for each client, known as the statewide unit record (UR) number
  • share select client level data between Victorian public Area Mental Health Services (AMHS) to support continuity of treatment and care
  • ensure the legal basis for providing treatment is evident to all public mental health service providers where a client may be unable or unwilling to consent to treatment
  • meet the various reporting requirements of the Department of Human Services
  • support the statutory functions of the Chief Psychiatrist and the Mental Health Review Board.

Recording diagnoses

Recording diagnoses assists in the clinical management of individual clients and provides essential information to guide the Department of Human Services in developing policies and priorities for resource allocation. It is also a mandatory data element in national minimum datasets as specified under the Australian Health Care Agreement to which the State of Victoria is a signatory.

'A diagnosis is the decision reached, after assessment, of the nature and identity of the disease or condition of a patient' (National Health Data Dictionary, Version 12).

Diagnoses represent the major or principal condition and other primary conditions, complications or co-morbidities and associated conditions treated or investigated during the relevant episode of care. Diagnoses must be coded in accordance with the agreed Australian Coding Standards - Victorian Additions, and advice as published from time to time in the Department of Human Services ICD Coding Newsletter.

Bed-based services

Acute

Every admitted episode of care must have a separation (1) diagnosis assigned within six weeks of the end of the month of separation. This requirement is aligned with the Victorian Admitted Episodes Dataset (VAED) reporting requirements for admitted episodes and is intended to assist health services in their compliance with the reporting requirements of both systems. Services may need to record diagnoses earlier to facilitate analysis of their outcome measurement data. Same-day stays for procedures, such as ECT, must also be assigned a separation (1) diagnosis.

Non-acute and residential

Separation (1) diagnosis must be entered in the same way as acute inpatient services (as above).

Non-acute and residential admitted episodes must also be assigned an admission (1) diagnosis.

These episodes of care must have an admission (1) diagnosis assigned within six weeks of the end of the month of admission (for episodes of less than one month the separation (1) diagnosis is sufficient).

Ambulatory community

Community clients

Registered community clients who do not have a case or episode, are required to have a community (1) event diagnosis recorded within four weeks of the end of the month of registration.

Community clients with case and episodes

Diagnoses for clients with community episodes (and therefore a case) must be assigned a community (1) diagnosis within four weeks of the end of the month of the episode start.

Ongoing community episodes are required to have that diagnosis reviewed and updated at intervals no further apart than 12 months (that is, within four weeks of the end of the month of the episode start date).

Case Closure

A diagnosis is required for the finalisation of the episode (case closure). If this is a community (1) episode the diagnosis must be entered within four weeks of the end of the month of the episode end (and therefore case closure).

If the final episode is from a bed-based service, diagnoses must be entered as outlined above.

Other

Other diagnosis events such as ISP (1) and assessment (1) are linked to the specific function. These diagnosis events are not mandatory and at this stage are for local use.

Where diagnoses are required for reporting to the Chief Psychiatrist (for example, ECT Register and Reportable Death Records), separation (1) or community (1) diagnoses are adequate for this purpose.

Further information

Information about the ICD-10-AM Australian Coding Standards (External links)

Victorian Additions to Australian Coding Standards and ICD Coding Newsletters

About program management circulars

The information provided in this circular is intended as general information and not as legal advice. Mental health service management should ensure that policies and procedures are developed and implemented to enable staff to collect and use health information and maintain data quality.

(1) These are actual diagnosis events and must be used at the appropriate occasion, such as 'Separation' diagnosis event to record the separation diagnosis