Skilled Nursing Facilities

Adding a Medical Diagnosis

You can add a medical diagnosis on the resident's record in one of four ways.

  1. Through the Medical Diagnosis module of the resident chart.

  2. Through the MDS Section I.

  3. While entering a Physician Order.

  4. Using the Add Diagnosis link available in the Active Diagnosis view of the Resident Dashboard.

The primary way of adding a diagnosis is through the Med Diag tab of the clinical chart. Regardless of where you access the Add Diagnosis option from, the basic steps of adding are the same.

  1. From the resident chart in the Clinical, click the Med Diag tab.

  2. Click BTNnewDiagnosis.png to add a medical diagnosis for the resident.

  3. Click in the Description field and type the diagnosis or a part of the description of the diagnosis. Then, click the magnifying glass icon lookup.gif at the end of the field to populate the code and description in the appropriate fields.

  4. In the Diagnosis Codes - All Diagnosis pop-up, click the [All Diagnosis] link to view a list of descriptions with the most appropriate options if the diagnosis does not appear in the Diagnosis list.

  5. Click the most appropriate option to populate the code and description in the appropriate fields.

  6. Click the Use admission date link to add the admission date as the date of the diagnosis, or type or select the date.

  7. Use the Classification and Rank lists to select the classification and rank of the diagnosis. For an overview of the concept of ranking and classifying diagnoses, see Medical Diagnosis - Rank and Classification Overview.

  8. To add further information about the resident and diagnosis, click in the Comments field and add a comment.

  9. Select Confidential if you need to hide the diagnosis from reports, but it still needs to be available through some reports for auditing purposes.

  10. Click Save to add the diagnosis, or click Save & New to continue to add another diagnosis for the resident.

  • Rank, Classification, and Confidential may not appear, depending on Diagnosis Configuration.

  • Having trouble finding a diagnosis? These 2 websites are excellent for searching hard to find diagnoses using common terminology:

  • You must have appropriate security to access the Medical Diagnosis tab of the resident chart and to add Medical Diagnosis.

  • The Rank field is a required field if database is configured to require this. You know the field is required if a red asterisk (*) is shown to the right of the field. This setting can be changed by a user with Medical Diagnosis Setup.