Introduction
The Diagnose command is used to document new conditions in a patient's chart.
Key Objectives:
- You will learn to document a new condition.
Video
FAQ:
Q: I made a mistake, how do I remove this command?
A: Commands can be entered in error, but not deleted. Please review the Entering a Command in Error document for directions.
Q: How do I print this command?
A: A command can be printed by using the triple dot menu to the right of the command and selecting the print option.
Tips & Tricks:
- Completing the background field is not required, but will help establish the documentation for the patient's active condition.
- If you enter a diagnosis that has previously been diagnosed for the patient, you will be prompted to "assess" the condition rather than enter it anew.. We will explain how to assess known conditions for a patient in a separate module.
Step by Step:
This process begins in an open note of the desired patient's chart.
- Type "diagnose" or "dx" into a blank line within the note.
- Select command by pressing Enter on the keyboard.
- Begin typing the desired diagnosis or ICD-10 code. A list of identical or similar options will populate.
- Select the desired diagnosis once populated by pressing Enter on the keyboard.
- Navigate through the fields by selecting Tab between each field
- Background: provide core anchor information from a patient's history that relates to the condition. Field has a 2048 character limit.
- Approximate Date of Onset: approximate start date using free text such as "last week", "3 years ago" or "2015"
- Today's Assessment: clinical thinking around the condition. Use this space to synthesize the current understanding of the problem from subjective and objective data acquired during the exam. Field has a 2048 character limit.
- Select DIAGNOSE to commit the command to the note.
NOTE: When committed, the entry immediately becomes visible on the patient summary as an active condition.
Roles:
- Provider
- Clinical Staff
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