Skilled Nursing Facilities

Medical Diagnosis Overview 

The Medical Diagnosis module is available when you access the resident chart from Clinical Services. This module allows medical diagnoses to be entered into the resident record using the International Classification of Diseases (ICD) library.

ICD codes were developed by the World Health Organization (WHO) to classify diseases in a globally consistent manner. The codes are identified by a number or number/character identifier (the Code) and a written description.

When medical diagnoses are entered in the resident's record in PointClickCare, the ICD codes automatically appear in the following areas:

  • Medication and Treatment Administration Records (MARs/TARs)

  • Admission and Discharge/Transfer Records

  • Assessments

  • Care Plans

  • Minimum Data Set (MDS)