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.
2. To add a new diagnosis to the chart, click the (+) icon next to the section header.
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.
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.
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
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.
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"?
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.
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.
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.
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.
For information on adding diagnoses to lab and imaging orders, please click here.