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