Once a diagnosis has been added, it can be edited if required or more diagnosis codes can be added to the existing list.
- Search for a Patient.
- Click Show.
- In the Main Menu, click Admissions.
- From the list of admissions, select the ARN (hyperlink) of the relevant admission.
- Scroll down to Diagnoses.
- To edit existing diagnosis, select the Edit button next to the relevant diagnoses.
- To add new diagnosis, Click New on the list of diagnosis.
- Complete fields using the table below as a reference.
Field Name | Pick List Options | Description |
|---|---|---|
Type* | •Principle •Co-Diagnosis •Complication •Additional •External Cause •Morphology | Refer to your clinical coding expert for what value to select |
Diagnosis* | •ICD10/Generic list | This is a pick list of ICD10 or generic codes that is loaded/managed by your system admin |
Condition Onset Flag* | •Arose during admission •Present on admission •Not Reported | Refer to your clinical coding expert for what value to select.
This value can be set as a default in CR Administration> Admission Categories |
Priority | Auto-populated free text value (whole number) | The system auto populates this value - the first diagnosis will be given Priority = 1, the second Priority = 2 and so on.
However, you can override this default value. |
*indicates mandatory field
9. If the Type "External Cause" is selected, additional field values will need to be entered:
Field Name | Pick List Options | Description |
|---|---|---|
Place of Occurrence | •ICD10 - Y range of codes | This is a pick list of ICD10 or generic codes that is loaded/managed by your system admin |
Condition Onset Flag for place of occurrence* | Arose During Admission Present on admission Not Reported | This value can be set as a default in CR Administration> Admission Categories |
Activity | •ICD10 - U range of codes | This is a pick list of ICD10 or generic codes that is loaded/managed by your system admin |
Condition Onset Flag for Activity | Arose During Admission Present on admission Not Reported | This value can be set as a default in CR Administration> Admission Categories |
10. Click:
a. Save - to add the diagnosis to the admission
b. Save & Add New - to add the diagnosis and return to the new screen to add another diagnosis
c. Cancel - to cancel and save no changes
11. Any equal or lower priority diagnosis entries will be demoted in priority to prevent duplicate priorities.
