To manually add a new diagnosis to the note, type search terms associated with the diagnosis (including all or part of the diagnostic name, nickname(s), and ICD-10 code) in any order in the "- Find DX to Assign -" bar in the Assessment box. Note that the EMR uses the ICD-10 diagnostic code database. Your diagnostic code shortlist (consisting of any codes you have used before) can be modified under Admin --> Manage --> Diagnostic Codes.
Diagnostic codes that are part of a note will automatically appear on any billing or insurance forms generated from the note. Once generated, billing and insurance forms can be manually edited.
Right-click any diagnosis that has been added to the note to:
- Make it the primary diagnosis,
- Add it to a patient's past medical history,
- Remove it from the note, or
- Manage the diagnosis definition (administrative function).
If it is a diagnosis for which additional information has been added to the system, you can also use the right click menu to add to the note:
- A description of the diagnosis,
- Common workup,
- Differential diagnoses, and
- Patient education.