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.
- To add a diagnosis or problem, click the Diagnoses & Problems tab.
- 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.
- Type Diagnosis, then click the Binoculars.
- Either SNOWMED or ICD-9 are acceptable.
- Select Diagnosis from the term list, and click OK.
- To remove a diagnosis, right click on the Clinical Dx, and select Remove Diagnosis from the drop-down box.