Health data standards and systems

In ACS 0002 example 11 the patient was advised by a nurse to drink more fluids as slightly hypotensive. In this example, the hypotension was not a significant condition in the episode of care, as the patient was only advised to drink more fluids; therefore it does not meet the criteria in ACS 0002.

If, following clinical consultation, a doctor documents a plan which would be considered routine care such as ‘encourage oral fluids’ would the condition still be considered clinically significant thus meeting the criteria in ACS 0002?

For example
Progress note
ATSP re ? BP
- BP 95/65 ATOR
- SOB comfortable
- Nil symptoms
- Drinking ++, IL jug this AM
- Feels well, nil dizziness
- TOV at 10:30 am
- Nil urine passed yet
- Not uncomfortable
Plan 1. Encourage oral fluids
2. Monitor TOV & urine

Discharge Summary
#Elective laparoscopic right hemicolectomy
-recovered well
-passed TOV
-discharged home

#Hypotension
-low BP at times throughout admission: asymptomatic
-Treated with oral fluids
-for GP R/V in 1 week please to ensure return to usual BP

If this example, does hypotension meet criteria for coding in ACS 0002 as the condition has been documented following clinical consultation and there is a prescribed plan of care?

Would the answer be different if the clinical consultation was not specifically for the hypotension (eg. hypotension noted during consultation for another condition with plan for oral fluids)?



Search Details
ACS 0002 Additional diagnoses examples 2, 3 and 11

VAHI Eleventh Edition Victorian education ACS 0002 Additional diagnoses

When considering whether a condition meets ACS 0002 Additional diagnoses, one of the following three criteria must be met:

• commencement, alteration or adjustment of therapeutic treatment
• diagnostic procedures
• increased clinical care

In example eleven of ACS 0002 Additional Diagnoses, drinking more fluids is not considered therapeutic treatment and there was no care plan or diagnostic procedure performed. However, in the case cited, VICC considers the hypotension meets ACS 0002 Additional diagnoses, as there was a clinical consultation, with documentation of a clinical assessment and a diagnosis and care plan for the condition. Therefore the criteria in dot point three of ACS 0002 Additional Diagnoses section titled Increased clinical care is met .

In answer to the final question, VICC considers that regardless of the reason the clinical consultation was initiated, there needs to be clear evidence that there was a clinical assessment completed for the documented diagnosis, in addition to a plan of care for the condition.