Adding a Diagnosis - Problems & Diagnosis Page
As a provider, placing your diagnosis codes for your patient's visit is very important. Depending on your work flow, there are several ways this can be accomplished.
The recommended workflow is through PowerNote. But if you use either dictation or a clinical notes template, here are a few other options.
This second video is how to add a diagnosis from the Problems & Diagnosis page.
Adding a Diagnosis - Summary Page Option
As a provider, placing your diagnosis codes for your patient's visit is very important. Depending on your work flow, there are several ways this can be accomplished.
The recommended workflow is through PowerNote. But if you use either dictation or a clinical notes template, here are a few other options.
This first video is how to add a diagnosis from the summary page.
Problems & Diagnosis Changes - Important Updates
PROBLEM & DIAGNOSIS CHANGES ON THE WAY
Most of these changes will take effect after March 11th, with the exception of the favorites folders being cleaned out, which will be closer to the end of March. Another newsflash will be sent at a later date with full education.
Understanding Vocabularies and the concepts of SEARCH and TARGET
IMO (Intelligent Medical Objects): this is a library of terms that are in provider friendly language. We will be using this terminology to for all SEARCH/LOOKUP of terms going forward. IMO terms are mapped to ICD-9, ICD-10, and SNOMED terms.
SNOMED is a terminology that has widespread use around the world but limited use in the USA. However, Meaningful Use Stage 2 (beginning now) requires that all terms on the problem list be SNOMED codes. So, SNOMED will be the TARGET vocabulary for the problem (patient-based) list.
ICD-9 and 10 terms are what we have to use for billing and will thus be the TARGET vocabulary for the diagnosis (encounter-based) list.
Bottom line: All SEARCH/LOOKUP will happen using IMO terms and all mapping to appropriate TARGET vocabulary will happen in the background.
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The search and target terminology will be changing for problems and diagnosis.
1) Problems favorites will be removed and the ability to save favorites will be unavailable.
The ability to save favorites will be enabled after the cleanup has finished.
2) For Problems, the search terminology will be IMO and the target vocabulary will
be SNOMED
3) All inactive problems will be changed to cancelled. This was a decision made by
Use and Standards regarding patients’ inactive problems showing on the patient
portal. By changing to cancelled these will no longer show on the patient portal.
4) The default columns for Problems will be changed for standardization across
all providers.
a) Annotated Display is what will display in the ambulatory summary and inpatient summary
on the consolidated Problems and Diagnosis section.
b) Condition name is the term you have used to search for the problem.
c) Life Cycle Status is the status of the problem
d) Vocabulary is the vocabulary that the problem is mapped to (SNOMED, ICD9, etc…).
5) Diagnosis favorites will be removed and the ability to save favorites will be unavailable.
The ability to save favorites will be enabled after the cleanup has finished.
6) For Diagnosis the search terminology will be IMO and the target vocabulary will be ICD-9
7) The default columns will be changed for standardization across all providers.
a) Priority is set by the physicians for each problem.
b) Annotated Display is what will display in the ambulatory summary and inpatient summary
on the consolidated Problems and Diagnosis section.
c) Condition name is the term you have used to search for the problem.
d) Code is the code that is associated to the target term vocabulary
