Medical treatment facility (MTF) commanders and clinical leaders closely monitor the number and types of patients evaluated, treated and evacuated from their facilities. This data is crucial in managing manpower and other resources which impact the mission, as well as the quality of patient care, and the completeness and accuracy of the electronic medical record (EMR). Annex G, Appendix G-3 of the Commander’s Guide to MC4 provides resources to help medical units proactively prevent problems that arise when a patient diagnosis is improperly documented or not accounted for at all.
The primary diagnosis for every patient encounter, as indicated by the ICD-9 code, must be appropriately assigned by the provider at the time of admission, or at least prior to discharge, transfer or evacuation. The ICD-9 code should reflect the patient’s condition or illness. The diagnosis then populates two databases: the Theater Medical Data Store (TMDS) and Medical Situational Awareness in Theater (MSAT). If a specific ICD-9 code is not entered, the databases will populate with “No Diagnosis.”
An incorrect or absent diagnosis code can rob the patient, the health care team, and the Veteran’s Administration of valuable information needed to provide care to the Soldier, plan for future treatment and rehabilitation, or submit disability claims.
Additionally, the absence of a specific diagnosis in TMDS and MSAT can deprive the command of the ability to accurately analyze illness and injury patterns, identify emerging health threats, and project future resource needs.
For example, the sudden appearance of multiple patient encounters for Salmonella Gastritis, which would appear in TMDS and MSAT as ICD-9 003.3, could alert the medical command to an outbreak of food-borne illness among Soldiers who ate at the same dining facility. The opportunity for intervention could be lost if the encounters were recorded as “no diagnosis.”
Similarly, a Soldier who is injured by a vehicle-borne improvised explosive device will likely need extensive treatment, rehabilitation and long-term care from the VA, in addition to screening for related injuries such as TBI and PTSD. The impact of the injuries on the Soldier, and the draw on resources to the command could be overlooked if the patient encounter is recorded as “no diagnosis.”
An outline of the sequence of events that support proper recording of patient diagnoses can be found in Annex G, Appendix G-3, of the Commander’s Guide. I encourage all deployable MTF commanders and clinical leaders to read this section of the guide to learn more about electronically admitting and dispositioning patients.