Diagnosis

The Patient file Diagnosis tab stores the patient's current diagnoses information. This information can print out on patient treatment plans, cover sheet and other reports. Claims can be configured to pull these codes if the payer doesn't require a Plan of Care for the patient. Otherwise claims are typically set to pull diagnosis codes from the Plan of Care record.

Click on Patient> Admit/Maintain, Diagnosis Tab

 To Add a record on the Patient>Diagnosis tab:

Adding/Maintaining Diagnosis Codes:

Press the   button to add the record.

Click on the drop-down list in the “Diagnosis” or “Description” fields, or click on the Find button to select the Diagnosis. Press the "ICD10" or "ICD9" button in the Diagnosis Search window to toggle between ICD10 and ICD9 code sets.

Onset-Date: Enter the Date the patient was diagnosed with that condition, if known.

Exacer-Date: Enter the date of exacerbation for that diagnosis

End-Date: Enter the date that condition ended for the patient:

**Note: Usually only current diagnoses are stored on this tab. The 485 Plan of Treatments will store the historical diagnoses.

Seq: Enter the sequence order the codes should appear in patient documentation.

 Diagnosis Group: Select a Diagnosis Group if needing to run reports based on diagnosis grouping. Typically only needed for reporting for certain States such as NY State Report.

Adding/Maintaining Surgical Procedures:

Select the “Surgical Procedures” button on bottom of screen.

Press the   button to add the record.

Click on the drop-down list in the “Procedure” or “Description” fields, or click on the Find button to select the Surgical Procedure.

Proc-Date: Enter the Date the patient was diagnosed with that condition, if known.

Seq: Enter the sequence order the codes should appear in patient documentation

 

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