Recording and Managing Diagnoses

This guide walks you through recording, editing, and reviewing a patient’s diagnoses as part of the Problem List the Clinical section of the Patient Chart. The Problem List is the primary list of a paitent’s clinical issues and and health conditions.

Before you start

You’ll need to have a patient chart open. The Problem List table lives under the Clinical section of the Chart Navigation.

How to record a new allergy

1. Open the patient’s chart and go to the Problem List table.
2. Select Add Diagnosis. This opens the Diagnosis modal.
3. Enter the Diagnosis. You can search using ICD-10 (preferred).
4. Add Clinical Status about the state of the condition. Defaults to Active.
5. Enter the Onset and Abatement dates of the condition, if known.
6. Add a Note if you want to capture free-text context about the medication statement.
7. Optionally enter additional details about the condition such as the servity, body site, stage and grade of the condition.
8. Review the Additional Information section if you need to set fields such as the verification status, date recorded, recorder, asserter, category. Encounters or supporting information linked to this condition may also appear.
9. Select Save.

How to edit an existing condition

1. In the Problem List table, select the row for the condition or diagnosis you want to update.
2. The Diagnosis modal opens, pre-filled with the existing information.
3. Make your changes and select Save.

How to search and filter the Problem List

• Search by name: Use the search box to find a condition or diagnosis by name or ICD-10 code.
• Filter onset of ababement date: Use to narrow the time window for the condition
• Status: User to filter by medication status such as Active or Completed.
• Sort: Select a column header to sort by Code, Description, Onset, Abatement, and Status.

Understanding what you’re looking at

Medication fields

Field	What it means
ICD-10	The ICD-10 code and description of the diagnosis or condition. Required
Clinical status	The clinical status of the condition. Defaults to Active for new conditions. Required
Severity	Subjective severity of condition
Body site	Anatomical location, if relevant
Onset	Onset date of the condition
Abatement	When in resoultion/remission
Note	Capture any additioanl free text about the condition
Summary	Stage/grade summary for a disease
Type	Type of stage of cancer and other conditions
Verification status	The verification status to support the clinical status of the condition
Date recorded	Date record was first recorded
Recorder	Who recorded the condition
Asserter	Person who asserts the condition
Category	Category assigned to the condition, e.g. Problem List, Encounter Diagnosis
Linked encounter	Links to encounter notes where condition was documented via macro
Supporting info	Links to other references such as diagnostic orders

How diagnoses are sorted

By default, the table sorts by condition onset in reverse chronological order, ICD-10 code, and then diagnosis description free text.

What the empty states mean

No diagnoses have been recorded or no records match the current filter.

If you’re not sure which state you’re seeing, check whether any filters are applied — clearing filters will show you the full picture of what’s on file for the patient.