Diagnoses & Problems 

Documenting a diagnosis is the provider’s responsibility. Nursing primarily documents the patient’s active problems.  This section of the chart does not impact the coding work done on discharge.

1. To add a diagnosis or problem, click the Diagnoses & Problems tab.  
2. Click on the Add button.  

NOTE: If entering a diagnosis (the problem that is being addressed during this encounter) click on the Add button below Diagnosis. If entering a problem, click on the Add button below Problems.

1. Type Diagnosis, then click the Binoculars.  
2. Either SNOWMED or ICD-9 are acceptable.
3. Select Diagnosis from the term list, and click OK.
4. To remove a diagnosis, right click on the Clinical Dx, and select Remove Diagnosis from the drop-down box.