Just like a story has an introduction, middle, and end, the medical record for a given encounter should show a clear flow of information from start to finish. It wouldn’t make much sense to read a story that started by setting the stage for a classic baseball showdown but ended with a discussion of baking brownies. Similarly, a medical record that starts with an encounter reason for visit (RFV) of “itchy eyes” but ends with a diagnosis of “cataracts” would leave the reader with questions about how cataracts created the itching.
Ultimately, each encounter should start with a clear reason that leads to a diagnosis that explains that reason and plan describing what you are going to do about it. The diagnosis that best explains the reason the patient is being seen is known as the primary diagnosis. It is certainly not uncommon for a given visit to have multiple diagnoses assessed, so how is a 3rd party to know which one you consider “primary”?
RevolutionEHR presents you with a tool to do just that and it’s called the “Set Primary” function. Let’s assume the following patient has glaucoma and diabetes and my RFV for the current visit was “3-month glaucoma evaluation as directed.” The order in which the diagnoses are listed on Today’s Diagnoses and the Plan suggests that diabetes is my primary diagnosis because it’s the first one listed:
This is less than desirable since diabetes doesn’t align with the primary reason the patient was being seen. However, if I use the “Set Primary” button on the Assessment screen, I can highlight glaucoma as the proper primary diagnosis:
Taking that action results in a green checkmark or a large “P” appearing next to the diagnosis (depending on the screen) to make it clear to anyone reviewing the record which diagnosis you consider the primary one to be:
Additionally, it results in the primary diagnosis properly appearing in position A on the CMS-1500 claim. Thus, it can be good practice to “Set Primary” for each encounter you provide that involves multiple diagnoses. The video below provides a demonstration of the associated workflow.