AMA Discharge Before Evaluation: Selecting the Correct Principal Diagnosis (PDX) for Abdominal Pain

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Question:


A patient was admitted for abdominal pain but left against medical advice (AMA) before being examined.


The emergency department (ED) notes documented a suspected small bowel obstruction (SBO) as the working diagnosis.


A CT scan of the abdomen showed:


1. Nonobstructive gastric and small bowel distention/gastroenteritis



2. Constipated fecal retention and advanced diverticulosis coli




Given the CT findings and incomplete evaluation, should a query be raised to clarify the etiology of abdominal pain, or is SBO the appropriate principal diagnosis (PDX)?

Answer:


1. Principal Diagnosis (PDX) Selection


The patient was admitted for abdominal pain, and SBO was documented in the ED as a working diagnosis.


The CT scan findings suggest gastroenteritis, fecal retention, and diverticulosis, but it does not definitively confirm SBO.


Since the patient left AMA before further evaluation, SBO remains the most appropriate PDX based on the available documentation unless further clarification is provided.



2. Query Consideration


A query may be needed if the documentation does not explicitly confirm SBO as the final diagnosis.


If the provider intended to rule out SBO, a query should be raised for clarification regarding the actual etiology of abdominal pain.



Final Decision:


If the provider confirms SBO as the reason for admission, it should be assigned as the PDX.


If uncertainty exists, a query should be raised to determine the correct diagnosis.








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