Diagnoses

Adding a Diagnosis to Your Chart

You can add a diagnosis section to the Assessment page of your SOAP chart and select from one of three diagnosis libraries:

• Basic diagnoses: Clear text (e.g., Hypertension, Cluster Headaches).
• Traditional Chinese Medicine (TCM) diagnoses.
• ICD-10 diagnoses: Used primarily for insurance and billing.

Steps to add a diagnosis:

• Click the green +A button at the top left of the chart editing interface.
• Select Diagnosis from the menu.
• In the Diagnosis section, use the dropdown list to search for and select the appropriate diagnosis.

Note: Diagnoses are labeled for easy identification — DX for standard, TCM for traditional, and ICD for ICD-10 codes.

📷 Interface image suggestion: Diagnosis section with search dropdown showing DX, TCM, ICD options.

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Differential Diagnoses

You can add differential diagnoses (DDX) in the same section.

• Use the second dropdown menu labeled Select DDX.
• Search and add potential alternative diagnoses.

📷 Interface image suggestion: Diagnosis section showing working diagnosis and DDX field.

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Making a Diagnosis Billable

By default, diagnoses are non-billable. You can mark them as billable if required for invoices or superbills. Options include:

• Billable Code: Adds only the diagnosis code.
• Billable Text: Adds only the diagnosis name.
• Billable Code + Text: Adds both name and code.

Hint: Billable diagnoses appear in the Express Checkout Dashboard Card, making it quick to include them in invoices or superbills.

📷 Interface image suggestion: Billing and status options panel for diagnoses.

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Setting the Diagnosis Status

Diagnosis statuses help track progress across visits. Available statuses:

• Active: New diagnosis or unchanged since last visit.
• Improved: Symptoms have reduced.
• Worsened: Symptoms have become more severe.
• Resolved: Condition is considered cured or stable.
• Incorrect / Not Applicable: Diagnosis was previously charted in error or is no longer relevant.

Note: Resolved diagnoses will no longer appear in the Client Workspace Medical Summary.

📷 Interface image suggestion: Diagnosis section showing status options (Active, Improved, etc.).

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Creating a New Diagnosis

OutSmart includes over 60,000 diagnoses, but you can create new ones when needed.

Steps:

• Add a Diagnosis section to your chart.
• Click the Menu button to the right of the Diagnosis Selection Box.
• Select Create Diagnosis.
• Enter a name, choose a library, and optionally enter a code.
• Click Create Diagnosis.

📷 Interface image suggestion: New Diagnosis creation window.

Hint: Only create new diagnoses when necessary to keep data consistent.

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Editing and Deleting Diagnoses

• Diagnoses cannot be deleted once created.
• Diagnoses can be edited (e.g., spelling corrections, clarifications).

Caution

Diagnoses are permanent and globally referenced. A diagnosis you created six months ago may already be cited in many charts, including locked ones. Editing the wording is fine for typos and clarifications; don’t repurpose a diagnosis into something different, because every past chart that referenced it will now appear to say the new thing. If you need a different concept, create a new diagnosis instead. Every edit is recorded in the audit trail.

Steps to edit:

• Add the diagnosis to a chart.
• Click the grey Menu button next to it.
• Select Edit Diagnosis.

📷 Interface image suggestion: Edit Diagnosis menu option.

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Best Practices & Considerations

• Choose the correct library: Use Basic, TCM, or ICD-10 depending on practice and billing needs.
• Limit custom diagnoses: Create new ones only when essential to maintain data consistency.
• Track patient progress: Update statuses (Improved, Worsened, Resolved) at each visit.
• Bill carefully: Apply billable options only when required for insurance or invoicing.
• Edit responsibly: Only adjust wording or spelling; never change meaning.
• Audit awareness: Remember edits are logged and may affect past charts if reopened.