🎞️ View video tutorial: Recording a diagnosis for an encounter
During an encounter, you can add one or more encounter diagnoses. Diagnoses that you add here are attached to the patient's chart. When you look back on a patient’s encounter history, you can see the diagnoses for each encounter, allowing you to quickly pick out and look back on visits for certain medical problems.
Once you've added a diagnosis to an encounter, you can also choose whether the diagnosis is automatically added to the patient's Medical History.
Also, when you create a bill for the visit, the added diagnoses can populate the bill automatically. For more information, refer to Customizing your encounter settings.
Steps
1. In the encounter, scroll down to the Assessment and Plan section.
2. Click the Add Diagnosis link.
3. In the Search box that appears, enter a diagnostic code or part of the description. Both the ICD-9 code and description are displayed in the list of matches.
⚠️ Important: The codes available depend on your billing province.
📌 Note: By default, the system displays the past 5 diagnoses associated with this patient from past signed encounters.
4. Select an item from the list.
5. To add the diagnosis to the patient's Medical History, click the toggle so it turns blue. This toggle is set to off by default, to help you avoid adding variations of the same diagnosis to the patient's Medical History.
📌 Note: The diagnosis is always saved with the encounter, even if you don't add it to the Medical History.
💡 Tip: To configure the default for this toggle, refer to Modifying your user preferences.
💡 Tip: If you are viewing an existing encounter, any diagnosis that was already added to the Medical History appears with a checkmark.
6. To add another diagnosis, repeat the steps above.
To remove a diagnosis, click the red X icon.
7. When you are finished the encounter, click Sign. Any diagnosis with an enabled toggle is added to the patient's Medical History.
Updated September 21, 2023