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Version: 3.1

How to record a diagnosis

Overview​

This flow describes how to record a diagnosis for a patient during an encounter. A diagnosis is one kind of condition in Care.

Pre-requisites​

  • The patient is registered in Care.
  • The patient has an encounter that is open. You cannot record a diagnosis in an encounter that is completed, cancelled, discontinued, or marked as entered in error.
  • You are a member of the facility that owns the encounter.
  • You have the permissions listed below.

Permissions​

PermissionAccess
Update Encounter related clinical dataLets you add, change, and remove diagnoses in an encounter.
Can view clinical data about patientsLets you see the diagnoses that the care team already recorded.

Steps​

1. Open the encounter​

  1. Open the facility.
  2. Find the patient, and open the encounter.

2. Open the diagnosis form​

  1. Select Encounter Actions.
  2. Select Add Diagnosis.

You can press d instead, while you view the encounter. The d shortcut opens the same diagnosis form.

3. Select the diagnosis​

  1. Select Add Diagnosis in the form.
  2. Enter the name of the diagnosis in the search box.
  3. Select the diagnosis from the list of results.

Care shows a warning if you select a diagnosis that the list already contains. Change the existing entry instead of adding a second one.

4. Complete the details​

Set the details of the diagnosis. Care fills the values in the Default column for you.

ComponentsWhat it capturesDefault
Onset DateThe date the diagnosis started. You cannot select a date in the future.Today
StatusThe course of the diagnosis, from Active to Resolved.Active
SeverityHow severe the diagnosis is: Mild, Moderate, or Severe.Moderate
VerificationHow certain you are about the diagnosis. Select Provisional or Differential while you still examine the patient.Confirmed
NotesFree text about the diagnosis.Empty

Repeat step 3 and step 4 for each additional diagnosis.

5. Save the diagnoses​

  • Select Submit to save the diagnoses to the encounter.
  • Select Save as Draft to keep your entries and finish later.

Expected Outcome​

  • The diagnoses show in the Diagnoses list on the Overview tab of the encounter.
  • The diagnoses show under Past Diagnoses in the clinical history of the patient.
  • Care records your name and the date against each diagnosis.

Concepts:

Flows: