Add a Diagnosis

1 On the Sig. dialog box, click Select Diagnosis.

2 In the Select Diagnosis box, do the following to select up to two diagnoses:

a Select a diagnosis by doing any of the following:

• Click the ICD-10 box to select an item from the list of patient Problems, Past Medical History items, or Diagnoses from the patient’s encounter note for the current day (if available).

If the problem or past medical history item you just selected is not coded in ICD-10, the Use ICD-10 for Diagnosis box automatically appears. If available, the most likely ICD-10 matches for the selected ICD-9 code appear from which you can select an item. If no matches appear, you can type three or more characters of the code or description in the ICD-10 box and click the most accurate match from the list. Click Add after selecting the diagnosis.

Note: If you need to remove and select another code, click next to the code.

• If you only know the ICD-9 code for a diagnosis, click the Use an ICD-9 to select ICD-10 link to enter an ICD-9 code and locate the appropriate ICD-10 and associated SNOMED codes. Once you have selected an ICD-10 code from the list of matches, click Add.

• Type three or more characters of the code or description in the Code/Description box and select an item from the list.

A second ICD-10 box appears after the initial diagnosis is added. If necessary, add a second diagnosis using one of the methods described above.

Note: If you need to remove a diagnosis that you have added, click .

b When finished selecting the diagnoses, click Save.

3 If you need to make changes to a diagnosis(es) that’s been added, click the diagnosis(es) on the Sig. dialog box and then remove or add a diagnosis from the Select Diagnosis box as described above.

Note: If you choose to add this medication or supply to your Favorite Meds or Favorite Supplies list while writing a prescription, the diagnosis information is not saved with the other Sig. details.