How do I add diagnoses to a patient chart?

Use Practice Fusion’s updated diagnosis search to quickly locate the most relevant ICD-10 codes when searching by ICD-9, ICD-10, or diagnosis description. Diagnoses can be added from within a patient encounter or directly from a patient’s Summary page and can be displayed throughout the chart by either ICD-10 code or diagnosis description. If specified, acuity will display beside each diagnosis, and the diagnosis detail pane (which includes mapped codes from other code sets and diagnosis comments) can be accessed by clicking on the diagnosis name.    

Adding diagnoses to the patient Summary
From the
Summary page of a patient’s chart, you can:

  • Search for a new diagnosis
  • Select a saved diagnosis from your My Dx list

1. Choose how you would like to display your patient diagnoses. Diagnoses can be displayed by Term or ICD-10 code.

  • Term: Displays the diagnosis term or description as provided by Practice Fusion’s health terminology vendor.
  • ICD-10: Displays the ICD-10 code and diagnosis description as provided by Practice Fusion’s health terminology vendor.

Note: When selected, this display setting will apply to the Summary, encounter Plan, and encounter Diagnoses.

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2. To add a new diagnosis to the chart, click the (+) icon next to the section header.

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3. Select a saved diagnosis from the My Dx list tab or search for a new diagnosis from the Search results tab using the diagnosis description, ICD-10 code, or ICD-9 code.

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If an orange badge appears next to the diagnosis when searching by ICD-9 code or diagnosis description, that is an indication that the diagnosis maps to multiple ICD-10 codes and will require further refinement. If the selected diagnosis needs further refinement, you will be presented with a list of potential ICD-10 codes. Use the Refine your search filters to narrow the list of diagnoses to choose from.

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4. Select the correct diagnosis, then enter any relevant diagnosis details:

  • Acuity: Indicate the appropriate acuity level using the Chronic or Acute radio button. Selecting an acuity is optional.
  • Start Date/Stop Date: Select from the relevant date fields. Note that selecting a stop date will mark the diagnosis as historical in the patient chart
  • Medications Associated with Diagnosis: Click Add next to the field header
  • Comments: Click Add next to the field header

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To view codes from other code sets that are mapped to the selected diagnosis, click the Show button next to Mapped Codes. These mapped codes include values from ICD-9 and/or SNOMED CT. You can also click the Patient education materials link to access resources specific to the selected diagnosis.

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5. Click Save to add the diagnosis to the chart or click Add another to continue adding diagnoses. Click the arrow next to Save for the option to Add to My Dx list. For more information on setting up the My Dx list feature, see How do I create and update "My Dx list"?

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Adding a diagnosis from within an encounter
Any diagnoses added from within a patient’s encounter will also be added to the patient's diagnosis list on the
Summary page. A diagnosis can be added to an encounter in two locations:

  • The Diagnoses section
  • The Assessment section of a SOAP note

Adding from Diagnoses
1
. To add a diagnosis from the Diagnoses section, click on an existing diagnosis or click Record next to the Diagnoses header.

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2. A modal window will open to the right of the page. Search for a new diagnosis from the Search results tab or select a saved diagnosis from the My Dx list tab.

3. Once the diagnosis has been selected, you can enter any relevant diagnosis details:

  • The diagnosis may be associated with the encounter by selecting the checkbox at the top of the window
  • Acuity can be indicated using the Chronic or Acute radio button
  • A start/stop date can be selected in the relevant date fields. Please note that selecting a stop date will mark the diagnosis as historical in the patient chart
  • Associated medications may be added by clicking Add next to Medications Associated with Diagnosis
  • General free-text comments may be added by clicking Add next to Comment
  • Free-text comments specific to the encounter may be added by clicking Add next to Encounter Comment.

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To view mapped codes, click the Show button next to Mapped Codes. You can also click the link for Patient education materials to access resources specific to the selected diagnosis to provide your patient.

4. Click Save to add the diagnosis to the chart or click Add another to continue adding diagnoses. Click the arrow next to Save for the option to Add to My Dx list.

Adding from the Assessment
1
. To add a diagnosis from the Assessment of a SOAP note, navigate to the section and click Record next to the section header. From the Assessment flyout pane in the modal window that opens, you can click Record to add a new diagnosis, Previous to attach an existing diagnosis, or My Dx list to select a saved diagnosis from your customized diagnoses list.

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2. If you select a diagnosis from the My Dx list or Previous tab, the diagnosis will automatically attach to the encounter. If you search for a new diagnosis from the Record tab, you will be able to add specifics including acuity, start/stop dates, associated medications, and comments once the diagnosis has been selected. Close the Assessment window to select Go to Plan to save your changes.

More information

For information on adding diagnoses to lab and imaging orders, please click here.

Charting

  1. How do I search for patients in the EHR?
  2. How do I customize my patient chart view?
  3. How do I complete a chart note?
  4. How do I use rich text editing when charting my encounters?
  5. How do I add diagnoses to a patient chart?
  6. How do I add a medication?
  7. How do I use flowsheets?
  8. How can I preview previous encounters and results while completing an encounter?
  9. How do I print a patient's chart or certain sections of the patient's chart?
  10. How do I print a chart note?
  11. How do I add past medical history (PMH), allergies, medications and diagnoses to an encounter?
  12. How to record and print patient demographics and profile
  13. What information is available in a patient's Timeline?
  14. How do I use the growth charts?
  15. How do I merge duplicate charts?
  16. How do I print the care plan?
  17. How do I open an existing patient chart?
  18. Can vitals be added in Metric Units or US Customary Units?
  19. How do I add advanced directives?
  20. How do I add allergies?
  21. How can I edit my signed chart note?
  22. How do I add Family Health History?
  23. What is the difference between a SOAP and Simple note?
  24. What are the Character Limits when Charting?
  25. What are the limits of simultaneous editing?
  26. What are Screenings/Interventions/Assessments?
  27. Where can I learn more about the different components of an encounter?
  28. How do I delete or deactivate a patient?
  29. How do I edit information on the Patient Summary?
  30. How can I view Diagnosis comments?
  31. How do I search for inactive patients?
  32. What are Clinical Decision Support (CDS) advisories?
  33. How do I change the date in an encounter?
  34. How do I populate the list of Frequently prescribed medications?
  35. How do I view more information for medications?
  36. Why am I receiving the error "Unable to sign" when trying to sign a chart note?
  37. How do I delete an unsigned encounter?
  38. Who can sign a chart note?
  39. How do you change the 'Seen by' provider in the new encounter?
  40. How do I add a patient?
  41. What information is required to save a patient's chart?
  42. How do I create a patient record number?
  43. How do I edit an existing SOAP or Simple Note?
  44. How do I record "Unknown Family History?"
  45. How do I pull history from one patient visit to the next?
  46. How do I refresh a patient's chart?
  47. How do I start a new note/encounter in Practice Fusion?
  48. How do I export a patient record (clinical document)?
  49. What is the file size of a patient image?
  50. Can I move a Patient Record Number from one chart to another?
  51. How do I view or update a patient's appointment within their chart?
  52. How do I add a custom medication?
  53. How many charts can be open and how do I close them simultaneously?
  54. How do I assign a Care Team?
  55. How do I add vitals to flowsheets?
  56. How do I customize my template line settings?
  57. How do I set my patient list and Timeline default?
  58. How do I attach a document to an encounter?
  59. How do I create and update "My Dx List"?
  60. How do I add custom allergies?
  61. How do I participate in the Prolia® Safety Program?
  62. How do I document patient risk score?
  63. How do I document an implantable device?
  64. How do I document social history?
  65. How do I add Goals and Health Concerns to the patient Summary?

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