Adding Diagnosis
You can add the diagnoses with the corresponding ICD-10 codes to the client record. Any diagnosis added to the client record before the Start of Care assessment pushes into the assessment. When the SOC assessment is saved and signed, any additional diagnoses added to the assessment push back into the client record.
From Case Details, click Diagnosis, click Edit and click Add.
Enter ICD-10 code.
Enter a few letters of the diagnosis. A list of diagnoses and codes appears. Select the diagnosis.
Select symptom: onset, exacerbation, or unknown.
Type the date.
Click Accept and click Save.
The first diagnosis entered is applied to the primary diagnosis classification. Additional diagnoses can be entered as needed.
To add additional diagnoses, click Edit and click Add.
To adjust diagnosis ranking, click adjust ranking arrows next to diagnosis classification.
Primary and secondary diagnoses can be edited to update, resolved or struck out.
You cannot sign an assessment if the primary diagnosis is not active.
You cannot delete a diagnosis if the diagnosis exists in the client chart.
The diagnoses cannot be updated on the Plan of Care/485.
The client diagnosis must be resolved or struck out to remove the diagnosis from the active diagnosis listing.
Any changes made to a diagnosis has an audit listing trail:
Created By - who created the diagnosis.
Created Date - when diagnosis was created.
Last Revision By - who revised diagnosis.
Last Revision Date - when diagnosis was revised.