Diagnoses Section

 

In the patient chart, click the Diagnoses chart tab at the left side of the screen.

 

1. In the patient chart, click the Diagnoses chart tab at the left side of the screen.

2. Click the plus icon in the upper right corner.
3. Enter the diagnosis you want to record and select it from the list.
4. Check the Primary diagnosis box if applicable.
5. Click the calendar icon to select an onset date if the default date is not correct.
6. Click NOTE to add a note about this diagnosis (optional).
7. Click Add.
   Note: You can also record a patient's diagnosis when adding a discharge order.

 

A primary or admission diagnosis and onset date is added to the Diagnoses chart section automatically when a diagnosis is entered in the hospital admission or transfer order H&P.

 

A problem is added to the Diagnoses chart section automatically when a diagnosis is recorded during a clinical encounter.

 

You can also add historical diagnoses, problems, and risks manually.

 

When you register a patient for a hospital visit, including an emergency department visit, the chief complaint selected at check-in time replaces diagnoses in the patient briefing and when adding an initial assessment.