The Diagnosis template enables the patient’s diagnosis or diagnoses to be selected.
Save Diagnosis Details
The Save Diagnosis Details screen is used to document, manage, and organize patient diagnoses during an encounter. The screen allows providers to search and save diagnoses, assign diagnosis details, document onset information, and control how diagnoses appear in patient notes and workflows.
ICD9 / ICD10: Used to select the diagnosis coding format.
Select/Search Diagnosis by Code or Description: Used to search and select diagnoses by code or description.
Education: Clicking this link after selecting a diagnosis from the Master List will open a pop-up window to a site called MedalinePlus®Connect. This webpage will provide more information on the diagnosis selected in Enabledoc.
Diagnosis: Displays or documents the selected diagnosis.
Location: Used to document the diagnosis location.
Chronic: Indicates the diagnosis is chronic.
Condition: Used to document condition-related information associated with the diagnosis.
Primary: Indicates the diagnosis is the primary diagnosis.
Type: Used to document the diagnosis type.
Resolved: Indicates the diagnosis has been resolved.
Onset Date: Used to document the diagnosis onset date.
Post-Operative Diagnosis: Used to document post-operative diagnosis information.
Remarks: Used to document additional diagnosis-related notes or comments.
Show In Note: Indicates the diagnosis should appear in the patient note.
Current & Historical Diagnosis: Displays both current and historical diagnosis records.
Pull Forward For Next Visit: Automatically carries selected diagnoses forward to the next patient encounter.
Lock: Locks the diagnosis record from editing.
Post To Care Dashboard: Posts diagnosis information to the care dashboard workflow.
Send Syndromic: Sends diagnosis-related syndromic reporting information when applicable.
Save / Cancel: Saves or cancels diagnosis entry changes.
The lower grid displays current diagnosis records including ICD code, diagnosis description, chronic status, primary diagnosis status, type, side, condition, resolved status, ICD10 status, note visibility, priority, and workflow actions including reorder, edit, delete, and mark historical.
Add Diagnosis
The Add Diagnosis screen is used to search, select, and add diagnoses to the current patient encounter. The screen allows providers to search diagnoses by code or description, assign diagnosis priority, identify primary diagnoses, and manage diagnosis coding formats.
ICD9 / ICD10: Used to select the diagnosis coding format.
Select/Search Diagnosis by Code or Description: Used to search and select diagnoses by code or description.
Diagnosis Grid: Displays selected diagnosis records including diagnosis description, chronic status, primary diagnosis status, priority, and ICD10 status.
Primary: Indicates the selected diagnosis is the primary diagnosis.
Chronic: Indicates the diagnosis is chronic.
Priority: Displays or manages diagnosis priority order.
Up / Down: Used to rearrange diagnosis priority order.
Delete: Removes the selected diagnosis from the encounter diagnosis list.
Favorites
Click this button to display a list of diagnosis the provider has added to the Favorites list. If there are more than eight diagnosis options listed, click the number at the bottom of the table to show the next eight options.
Diagnosis Search
The Search tab within the Diagnosis module is used to search and add diagnoses to the current patient encounter. The Search screen contains two tabs: Codes Search and Indexed Search.
Codes Search
The Codes Search tab is used to search diagnoses using ICD codes, diagnosis descriptions, or problem-related keywords.
Diagnosis: Used to search diagnoses by ICD code or diagnosis description.
Problem: Used to search diagnosis-related problem descriptions or keywords.
Save Diagnosis: Saves the selected diagnosis to the current encounter diagnosis list.
Indexed Search
The Indexed Search tab is used to browse and search diagnoses alphabetically using indexed diagnosis listings.
Alphabet Index: Used to filter diagnosis listings alphabetically.
Search: Searches indexed diagnosis entries.
Diagnosis List: Displays indexed diagnosis descriptions with associated ICD codes and billable or non-billable status indicators.
Selection Checkbox: Used to select diagnoses for addition to the current encounter.
Save Diagnosis: Saves the selected diagnosis to the current encounter diagnosis list.
History
The History tab within the Diagnosis module is used to review previously documented patient diagnosis records and add historical diagnoses to the current encounter or patient note.
Add To Todays Diagnosis: Adds selected historical diagnoses to the current encounter diagnosis list.
Select to Show in Note: Marks selected historical diagnoses to appear in the patient note as historical information.
The history grid displays previously documented diagnosis records including ICD9 code, ICD9 description, ICD10 code, ICD10 description, diagnosis type, side, condition, resolved status, ICD10 status, encounter date, and options to add diagnoses as primary or chronic diagnoses.