1. To add a diagnosis, click Diagnosis & Problems in the Menu column within the patient chart.

Transcription

1 1 of 15 DIAGNOSIS & PROBLEMS Add and Remove a Diagnosis Add a Diagnosis 1. To add a diagnosis, click Diagnosis & Problems in the Menu column within the patient chart. 2. Click Add. NOTE: If the patient was admitted through the ED, diagnoses may already be displaying in Diagnosis (Problem) being Addressed this Visit if a diagnosis was entered by the ED triage nurse and/or the ED physician/lip. There are two primary ways to add a diagnosis in Diagnosis & Problems which will be reviewed: Search for a diagnosis using the Diagnosis search field. Utilize the available folders located in the tabs listed in the bottom portion of the screen.

2 2 of 15 Add a Diagnosis Using the Diagnosis Search Field 3. Type the diagnosis in the highlighted Diagnosis field. 4. Click the Binoculars.

3 3 of The Diagnosis Search window displays. To select the appropriate diagnosis, double-click a diagnosis or select a diagnosis to highlight it and click OK. NOTE: Prior to clicking OK, the selected diagnosis in the Diagnosis Search window may be added to Favorites by clicking Add to Favorites. This will be reviewed later in the material. Diagnosis List Fields and Functions 6. The Responsible Provider field automatically populates with the name of the physician entering the diagnosis.

4 4 of The *Type field automatically defaults to the option, Reason For Visit. The *Clinical Service, *Date, *Confirmation and *Classification fields also automatically populate with information. If information needs to be changed in a field, click the drop down arrow beside the field to choose another option. NOTE: The following options are available when a diagnosis is being added: OK - Adds the selected diagnosis. OK & Add New - Adds the selected diagnosis and allows an additional diagnosis to be selected and added. Add Problem & Diagnosis - Adds a selected diagnosis as a problem and a diagnosis. Cancel - Removes the diagnosis selection prior to being added. Add an Additional Diagnosis 8. If an additional diagnosis needs to be added, click OK & Add New to add the selected diagnosis and then select an additional diagnosis to be added.

5 5 of The diagnosis will display under Diagnosis (Problem) being Addressed this Visit and the Diagnosis field is highlighted so that another diagnosis may be added. 10. Perform the following steps to continue adding an additional diagnosis: a. Type the diagnosis in the Diagnosis field. b. Click the Binoculars. c. Select the appropriate diagnosis from the Diagnosis Search window and click OK. d. Click OK to add the diagnosis.

6 6 of 15 Diagnosis List Tabs A diagnosis may be added from the folders located in the following tabs listed in the bottom portion of the Diagnosis List window. These tabs include the Home tab, the Favorites tab, the Folders tab and the Previous Diagnosis tab. Each of these tabs will be reviewed: Home Tab The Home tab contains a list of diagnoses from a specialty folder that is set by the provider as the Home folder. Setting a specialty folder as the home folder makes the diagnoses within the folder more accessible. Setting a Home Folder default and adding a diagnosis from the Home folder will be reviewed: Set a Home Folder Default and Add Diagnosis from the Home Folder While adding a diagnosis, a specialty folder may be set as the Home Folder. When this is done, the folder will default open making the search for diagnoses easier.

7 7 of 15 When Add is clicked, the Diagnosis & Problems window will initially display with the Folders tab defaulting open with a list of specialty folders. 1. To set a specialty folder as the Home Folder, right-click the appropriate folder from the list of specialty folders and click Set as Home Folder.

8 8 of The next time Diagnosis & Problems is accessed, the Home tab will default open displaying the diagnosis list from the specialty folder that was set as the Home Folder. To add a diagnosis from the list in the Home folder, double-click the appropriate diagnosis and click OK. 3. The diagnosis will display under Diagnosis (Problem) being Addressed this Visit. Favorites Tab The Favorites tab contains customized folders with commonly used diagnoses and problems that have been saved and organized by the provider using the Add to Favorites feature. Add to Favorites There are two ways to add a diagnosis to Favorites: Click Add to Favorites in the Diagnosis Search window after selecting a diagnosis.

9 9 of 15 Right-click and select Add to Favorite from the drop down menu on a diagnosis already listed in Diagnosis (Problems) Already Addressed this Visit. Each of these options will be reviewed: Add a Diagnosis to Favorites Using the Diagnosis Search Window 1. Perform the following steps to add a diagnosis to Favorites from the Diagnosis Search window: a. Type the diagnosis in the Diagnosis field. b. Click the Binoculars. 2. The Diagnosis Search window displays. To add a diagnosis to Favorites, select a diagnosis to highlight it and click Add to Favorites. 3. The Folder Maintenance window displays. Diagnoses may not be added directly into the Favorites folder. A sub-folder must be created. Click Create Folder.

10 10 of To name the new sub-folder, type the name in the highlighted area. 5. Click Enter or click in the white area to display the newly created sub-folder. NOTE: Additional sub-folders may be added by clicking Create Folder. When creating additional sub-folders, click on the Favorites folder at the top, so the newly created folder will be a sub-folder of the Favorites folder. If another folder is highlighted and Create Folder is clicked, the new folder will be a sub-folder of that folder. 6. To add the diagnosis to the subfolder, select the new sub-folder to highlight it and click OK in the Folder Maintenance window.

11 11 of To continue adding the selection as a diagnosis: a. Click OK in the Diagnosis Search window. b. Click OK in the Diagnosis & Problems window. The diagnosis will display under Diagnosis (Problem) being Addressed this Visit. 8. The Favorites tab will default open if the provider has not set a particular folder as the Home Folder. Click the sub-folder to view the diagnosis that was added as a favorite. If a Home Folder has been set, the Home tab will continue to default open and the provider will need to click the Favorites tab to view the newly created subfolder. Click the folder to display the diagnosis that was just added. 9. The diagnosis will display and is easily accessible to add as a diagnosis in the future by following the same steps previously reviewed in adding a diagnosis from the Home Folder. NOTE: To organize the Favorites folders, click the drop down arrow to the right of the Favorites tab and select Organize Favorites. Add a Diagnosis to Favorites Using the Right-Click Function A diagnosis may also be added to Favorites by using the right-click function and selecting Add to Favorite from the drop down menu on a diagnosis already listed in Diagnosis (Problems) Already Addressed this Visit. The Folder Maintenance window will display. Follow the steps previously reviewed to continue adding the diagnosis to Favorites.

12 12 of 15 Folders Tab The Folders tab contains specialty folders, which contain specific diagnoses related to the specialty. As stated earlier, the Folders tab will default open initially until a Home Folder default has been set by the provider or a diagnosis is added to Favorites. To add a diagnosis from a specialty folder, click the appropriate folder, double-click the appropriate diagnosis and click OK. Previous Diagnosis Tab The Previous Diagnosis tab contains diagnoses added from a previous encounter. To add a diagnosis from this tab, double-click the appropriate diagnosis and click OK. A Problem may be added by following the same basic steps using the Problems area in Diagnosis & Problems. Remove a Diagnosis from Diagnosis & Problems When adding and/or removing a diagnosis using the Modify function or the In Error function in a clinical note in Notes, information will not flow forward into Diagnosis & Problems. The diagnosis must also be added and/or removed in Diagnosis & Problems. 1. To remove a diagnosis from Diagnosis & Problems, click Diagnosis & Problems in the Menu column within the patient chart.

13 13 of Right-click the diagnosis and select Remove Diagnosis from the drop down menu. 3. The diagnosis displays with strikethrough in each column. NOTE: A Problem may be removed by following the same basic steps using the Problems region at the bottom of the Diagnosis List window. Diagnosis and Problems Right-Click Functions More functions may be performed by right-clicking the diagnosis and/or problem listed in the Diagnosis & Problems window and choosing from the menu options. Diagnosis options include: Add Diagnosis Adds a diagnosis. Modify Diagnosis Changes or adds details to a diagnosis. View Details View all details including additional details. Remove Diagnosis Marks the diagnosis with strikethrough lines. Add to Problem List Adds the diagnosis as a problem on the Problems list. Convert to Problem Converts a diagnosis to a problem. Medline Search Links to resource material regarding the diagnosis.

14 14 of 15 Add to Favorite Adds a diagnosis to Favorites. Properties Adds columns and customizes the Diagnosis (Problems) being Addressed this Visit view. Problem options include: Add Problem Adds a problem. Modify Problem Changes or adds details to a problem View Details View all details including additional details. View Problem History Displays history details of problem including the provider who entered the problem. Add to Diagnosis Adds the problem as a diagnosis in Diagnosis (Problems) being Addressed this Visit Convert to Diagnosis Converts a problem to a diagnosis. Medline Search Links to resource material regarding the problem. Add to Favorite Adds a problem to Favorites. Properties Adds columns and customizes the Problems window view.

15 15 of 15 NOTE: Diagnoses and Problems may also be added in Orders from the Add Order window.