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.