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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. Click to View Screenshot in New Window 
  2. Click on the Add button. Click to View Screenshot in New Window 

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. Click to View Screenshot in New Window 
  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.

Related Content:

Icon Diagnosis and Problems
Documenting a diagnosis is the provider's responsibility. This 3 page document walks the provider through the steps of documenting patient diagnoses and problems.