Selecting a Diagnosis

Use the Diagnosis tab to select diagnosis and ICD information:

1. From the buttons located above the Diagnosis Grid, click New.

2. Check the box next to one of the following to designate the type of diagnosis:

● Primary if this is the primary diagnosis.

● Admitting Diagnosis if this is the diagnosis given at admission.

By default, Enterprise Edition will populate the Seq field with a "1" for the primary diagnosis that is selected and saved.

3. If you know the exacerbation or onset date of the patient's diagnosis, enter this into the middle section of this screen:

● Using the drop-down menu below the Description field, select Exb Date or Onset Date.

● Enter the corresponding date, using mm/dd/yyyy format, in the blank text field or click and select the date from the pop-out calendar.

4. If the diagnosis is related to a patient's terminal condition (if applicable), check the box next to Related.

5. Use the fields in the ICD Reference Search to search for the specific diagnosis.

6. Locate and click on the diagnosis in the list to select it then click . Enterprise Edition displays the diagnosis in the grid at the top of the screen.

You can reorder the diagnosis codes in the list by dragging and dropping them with the mouse. Anytime you drag and drop a diagnosis, you must click Save to save the changes. The saved sequence will flow to the 485.

7. Ensure that each patient's chart is ready for the transition to ICD-10 by Crosswalking Diagnosis Codes.

8. Click to apply pending changes and continue with Identifying Surgical Codes.

9. Use the fields in the ICD Reference Search to search for the specific diagnosis.

10. Locate and click on the diagnosis in the list to select it then click . Enterprise Edition displays the diagnosis in the grid at the top of the screen.

11. Ensure that each patient's chart is ready for the transition to ICD-10 by Crosswalking Diagnosis Codes.

12. Click to apply pending changes and continue with Identifying Surgical Codes.