Diagnosis and History

In  CareRight there are several areas where a diagnosis is recorded.  Each area is related and performs a specific function.

The following areas have a diagnosis, working diagnosis and problems:

• Patient medical record
• Admissions.

The Diagnosis and Problems serves multiple purposes:

• Record active diagnosis
• Record provisional diagnosis
• Record hospital admission diagnosis.

Diagnosis Types

Users will record diagnosis as a way of documenting the illness of a patient.   There may be different ways of entering diagnosis (free text or pre-defined).  This will be based on your organisational needs.  

Working Diagnosis 

A working diagnosis  is where a confirmed diagnosis is unavailable.  This may be a provisional diagnosis and may require the results of laboratory tests or further psychological evaluation to become a confirmed diagnosis.

Viewing Diagnosis and Problems

To view current or historical diagnosis and problems, open the patient record and click on the Diagnosis & History tab.

Items can be ordered, this would mean that one possible diagnosis is more critical than another.  If a diagnosis has been made in error, this can be struck out.  You can also edit the diagnosis (by clicking Edit) or a new diagnosis can be created from this screen.

Creating a Diagnosis

Click New Diagnosis or New Working Diagnosis to create a new item.  Both screens are the same but choosing which one will depend on the patient situation.

• The date will pre-populate but can be modified.
• Select a diagnosis from a pre-defined list, or free text a diagnosis
• Click Create Diagnosis.

The new diagnosis will appear in the main screen and be struck out (if an error has been made) or edited again. Follow the same steps for problems.

Managing Diagnoses

The Diagnoses panel offers several options to manage individual diagnoses — these include Close, Strike Out and Edit. Instructions for the usage of each are as follows:

How to Close a Diagnosis

1. Click Close for a diagnosis.
2. In the warning panel, click OK.
   1. The diagnosis will move to the History tab and the end date will change to today's date — the Strike Out tool can still be used on a closed diagnosis.

How to Strike Out a Diagnosis

1. Click Strike Out for a diagnosis.
2. In the warning panel, click OK.
   1. The diagnosis will move to the History tab and it will be marked as Strike Out.

How to Edit a Diagnosis

Editing a diagnosis is used to change the end date.

1. Click Edit for a diagnosis.
2. In the End Date field, click the mini-calendar icon and select a new ending date.
3. Click Update Diagnosis.