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Adding a new diagnosis to your chart is as simple as adding a diagnosis section to your chart’s Assessment page, and then selection from a list of diagnoses. OutSmart has 3 diagnoses libraries:
All three of these libraries are available from the same drop down menu when adding a diagnosis. To add a diagnosis to your chart, click on the green ‘+A’ button at the top left of the chart editing interface. This will open up a menu of various sections you can add to your Assessment. Select ‘Diagnosis’ from that list. This will add a diagnosis section to your SOAP chart, in the Assessment page.
Adding a diagnoses section to your SOAP chart
Once the section has been added, you can select a diagnoses from the first drop-down menu at the top left of the section. This is the diagnosis list. Start typing in the diagnoses you are looking for, and the list will start filtering and showing results that match your search term. Once you find what you are looking for, click on it to add it to your chart. Note that diagnoses with the yellow ‘DX’ label indicate standard diagnoses, the ‘TCM’ label indicate TCM diagnoses, and the ‘ICD’ label indicate ICD-10 codes.
All three ‘standard’, ‘TCM’, and ‘ICD’ diagnosis libraries can be found in the same searchable menu.
Once you select your working diagnosis, you can then add differential diagnoses (DDX) in the same manner, using the 2nd diagnosis drop down menu in the section, labelled ‘Select DDX’.
Once selected, a diagnosis is by default marked as non-billable. This means that you do not intend for this diagnoses to be indicated on the patient’s invoice or superbill. In some regions, you may want to do this because it is a requirement for insurance purposes. In those cases, you have 3 options to choose from to add the diagnoses to the patient’s invoice or superbill:
Billing and Status options for Diagnoses.
When you select one of the billable options, the diagnoses will show up itemized in the Express Checkout Dashboard Card, which will allow you or your staff to quickly and easily add it to an invoice or superbill.
The status if a diagnoses will help you to better understand whether or not the patient is improving, or worsening. There are 5 possible diagnosis statuses:
Note that marking a diagnoses as resolved will cause this diagnoses to no longer show up in the Client Workspace under the Medical Summary section.
Although OutSmart has over 60,000 diagnoses loaded into our library, there is always the possibility that the diagnosis you want to add to your chart is not available. In this case, you can create your own.
Once you have added a diagnosis section to your chart, click on the Menu button to the right of the Diagnosis Selection Box, and then select “Create Diagnosis”. This will open the diagnosis creation window.
Create a new diagnosis.
Enter your new diagnosis name, choose a diagnosis library to add it to, and then enter a diagnosis code if desired. When you are done, click on “Create Diagnosis”.
Enter the details of your new diagnosis.
Once a diagnoses has been created, it cannot be deleted from the system, but it can be edited, in case there is a spelling error or something similar. It’s important to note that editing a diagnoses can have retroactive effects on the same diagnosis in previous charts, if you ever open up that previous chart and re-save it, or if the chart is unlocked. So it is important, for the consistency and utility of your data, that you do not edit a diagnosis and change it into something completely different. Editing a diagnoses should only be reserved for instances where you are clarifying it, or adjusting wording or spelling, but not changing it entirely into a different diagnosis.
Note as well that audit-trail records are kept in the system when diagnoses are edited.
To edit a diagnosis, start by adding it to the chart. Once you have added the diagnosis to the chart, you can then click on the grey menu button to the right of the diagnosis, and select ‘Edit Diagnosis” from the menu.
Editing a diagnosis.