Manually Entering Diagnosis Code
Manually Entering Diagnosis Code
If a diagnosis code cannot be found in the pre-populated diagnosis entries, one can be manually entered in the work areas of a note.
Within a note, under diagnosis, select Enter:
Which brings up this window:
Type in your chosen ICD-10 code in the first available entry box then hit the Tab or Enter key on your keyboard to populate the description for your code:
You may do this for as many diagnosis codes as needed for your note
You may set one more diagnosis/es as Rule Out (R/O) by checking the R/O box to the right of the diagnosis, as well as set the SNOMED status by clicking in the dropdown field (set to Active by default) and provide a POA (Present on Admission) code.
When all diagnoses are entered, click the Done button:
You will then be returned to your note with the newly entered diagnosis code(s)
This is how it will look in the compiled note
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