Dx (Diagnosis) Tab

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Diagnosis (Dx) Tab

  • The note must have a diagnosis that correctly corresponds with labs or procedures that have been ordered. 
  • Select the Dx in one of the following four ways.  The Differential list appears based on the Chief Complaint for this patient. 
    1. Choose the appropriate specialty from the picture
    2. Search using the search field
    3. Select Active Problems to list the current complaints
    4. Choose from the Common or Differential lists.
  • The Common list is created by the physician as complaints are added to the Hot List. 
  • The generic picture for the patient contains multiple specialties which can be selected to get appropriate options for the diagnosis.  By drilling down through the images, the specific Dx can be selected.
  • The Dx tab will display a list of possible diagnoses when there is a Chief Complaint chosen.  For example here, Betty Boop is suffering from insomnia following the death of her husband so her Chief Complaint(CC) is Insomnia.  Going to the DX tab brings up a list of related diagnoses. 
  • When Adjustment Insomnia is selected as the Dx, the name and code are shown in the box below the picture. 
  • There is a check mark to indicate this Dx is Active. 
  • If a mistake is made, the X box will remove that Dx from the list. 
  • Clicking on the Dx name or the Annotation icon (three dots in parentheses following the name and ICD-10 code), a popup gives further options for details about this Dx. 
  • Clicking on MDM allows specification of the Medical Decision Making for this encounter.
  • Other Comments is a space for the provider to add any further relevant information.
  • Using the Search box to locate a specific diagnosis is shown below, after the Dx is made. 
  • Patient Risk can be set on the Dx page by clicking the button on the upper right side of the page.
  • Patient Risk parameters are defined for the clinic in the Admin module under Patient Risk.