Entering Patient Problems

The Problem List module lets you collaboratively manage patient problems (diagnoses). This is particularly useful in settings where there are several clinicians on the team (intern, resident, fellow, attending) or where night float residents typically cover the nights before signing out to the day team. Providers can add or modify a patient’s clinical problems to update other team members who also have a relationship to the patient. The problems on a patient’s Problem List can come from a variety of sources, listed below. In all cases below, the Commure Pro system keeps track of the date a problem was last used, so that providers can easily identify the most recent or chronic problems for a patient.

• Problems might be entered in your source system and then interfaced to the Commure Pro system.
• Problems can be entered as the diagnosis on a completed charge transaction in the Charges module. (Problems associated with draft charges are not added to the Problem List.)
• Problems can be entered as part of a completed clinical note in the Clinical Notes module. (Problems associated with draft notes are not added to the Problem List.)
• Problems can be entered as the reason for an order in the CPOE Orders module. (Problems entered as a “rule out” reason on an order are not added to the Problem List.)
• Problems can be entered or modified for patients, independent of charges/notes/orders, directly in the Problem List module. This chapter reviews the last bullet above: how to enter or modify problems for patients in the Problem List module. However, some of the functions described here relating to selecting a problem (from a Favorite Diagnoses list, Existing Problems list, Department Pickers list, Searching, or Free Text), are also used in the other modules mentioned above.

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Adding a New Problem in the Problem List Module

To add a new problem for a patient directly in the Problem List module, follow these steps:

1. From the Problem List, tap Add , located at the top right of the screen. The Diagnosis Picker screen is displayed.
   If you had previously used the Keep Open option for a particular category, then that category is automatically displayed as a starting point when you first access the Diagnosis Picker screen (see Keeping a Diagnosis Category Open). If you want to choose a diagnosis code from a different category, tap Back to go back to the main Diagnosis Picker screen.
2. Select a problem using any of the standard methods below.
   • Selecting Diagnoses from Lists (Favorites, Existing, Latest Used, or Pickers)
   • Selecting Diagnoses Using the Search Option
   • Entering Diagnoses as Free Text After selecting a problem, the Add Problem screen appears with the selected problem listed at the top of the screen. If you selected a Diagnosis Macro Group, the macro group’s description is displayed.
3. Enter the appropriate information for the problem (depending on your system configuration, not all fields may be editable). Please note that if you selected a Diagnosis Macro Group, all of the attributes below are applied to all of the diagnoses in the group.
   • Onset: Enter the date of onset for the problem.
   • Diagnosed: Enter the date the patient was diagnosed with this problem.
   • Resolved: Enter the date the problem was resolved. When you enter a date here, the Status field is automatically set to Resolved.
   • Last Used: This read-only field represents the date and time this problem was last used for this patient on a charge, note, or order. When adding a new problem, the current date and time is automatically saved as the last used date.
   • Type: Select the type of problem. Your choices are Acute and Chronic. The default is Acute.
   • Status: Select a status that describes the problem, such as Active, Inactive, Resolved, or Cancelled. The default is Active.
   • Codes: This read-only field shows all of the code designations for this problem, according to the various classification systems (ICD-9, ICD-10, and Snomed).
   • HCC: This read-only field indicates whether the diagnosis is an HCC driver meaning that it drives the revenue up in capitated Medicare Advantage plans.
   • Created: This read-only field shows the date the problem was initially created.
   • Source: This read-only field shows the source from which this information was derived. Since the problem is being entered directly in the Commure Pro system, the source is automatically set to “MANUALLYADDED.” This field is present only if your organization has implemented Commure Pro’s HIE option. See Viewing the Source of Clinical Data (HIE).
4. Tap Save. The Problem List Summary is displayed. If you entered a single problem, it is added to the patient’s problem list and can be seen in the Problem List Summary. If you used a Diagnosis Macro Group, each problem in the group is added as an individual item to the patient’s problem list, and is displayed independently in the Problem List Summary. All of the attributes that you selected in Step 3 are applied to each problem.

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Selecting Diagnoses from Lists (Favorites, Existing, Latest Used, or Pickers)

There are several options that allow you to select diagnosis codes from a list, including Favorite Diagnoses, Existing Problems, Latest Used Problems, and Department Pickers. Each list contains different types of diagnosis codes, and can also include Search Terms or Diagnosis Macro Groups.

• Search Terms are partial codes or phrases that immediately execute a search. For example, if you tap on a search term called “chest pain,” the words “chest pain” automatically populate the Search field and all diagnoses containing that phrase are immediately displayed. Similarly, tapping on a Search Term of “R07.8” would immediately show all diagnoses containing those numbers, such as R07.81, R07.82, and so on. Since a Search Term is essentially a short cut to executing a search, see also Selecting Diagnoses Using the Search Option for more information about using the Search feature. Search Terms are preceded by a search icon so that you can distinguish them from regular diagnosis codes:
• Diagnosis Macro Groups are a time-saving feature that allow you to enter an entire group of related diagnosis codes with a single tap. For example, a diagnosis macro group might consist of a primary diagnosis along with the secondary diagnoses that usually accompany it. Just select the diagnosis macro group, and all of the codes are automatically added to the charge, note, or problem list (diagnosis macro groups are not available when entering orders). Diagnosis macro groups are preceded by a gears icon so that you can distinguish them from regular diagnosis codes: The items that are included in each type of list are as follows:
• Favorite Diagnoses: This option displays your personal list of favorite diagnosis codes and Search Terms, and is available only if your administrator has enabled it in your user profile. Where this list can be used: The Favorite Diagnoses list is available when entering charges, orders, clinical notes, or when entering problems directly in the Problem List module.

For instructions on how to add a code or Search Term to your favorites list, see Adding or Removing Items to/from your Favorite Diagnoses List and Saving a Diagnosis Search as a Search Term on Your Favorites List.

• Existing Problems: This option displays a list of the patient’s active diagnoses, which is pulled from the patient’s problem list history. How do diagnoses get onto the patient’s problem list? Diagnoses that you or others enter on the patient’s charge transactions, orders, or clinical notes are saved to that patient’s problem list. In addition, users can manually add diagnoses to a patient’s problem list in the Problem List module. (The problem list does not include problems that were used on draft charges or as a “rule out” reason on an order.) Where this list can be used: The Existing Problems list is available when entering charges, orders, or clinical notes. It is not available when entering problems directly in the Problem List module.
• Latest Used Problems: This option displays any problems you recently selected for this patient in the current ordering session. Where this list can be used: The Latest Used Problems list is available only when entering orders.
• Department Pickers: This option displays a categorized list of diagnosis codes created specifically for your department by your administrator to make it easier for you to find the codes you need. When using the Department Pickers list, you progressively drill down through the categories to find the specific diagnosis that you want. The Department Pickers list contains individual diagnosis codes and can also contain Search Terms or Diagnosis Macro Groups, if your department administrator has added them to the Department Pickers.

Where this list can be used: The Department Pickers list is available when entering charges, orders, clinical notes, or when entering problems directly in the Problem List module. (When entering orders, Diagnosis Macro Groups are not available on the Department Pickers list.) Each option is either a flat list of codes, or a categorized list of codes. You simply select the option to see its contents, view the items or subcategories within it, and then select the item you want. There are additional tools available to help you quickly identify the correct code within the list options. See Viewing Numeric Codes, Charge Guidelines, or HCC Information. To select a diagnosis code using one of the list options, follow these steps:

1. Start the process for entering a diagnosis on a charge transaction, an order, a note, or directly in the Problem List module. The Diagnosis Picker screen appears.
   If you had previously used the Keep Open option for a particular category, then that category is automatically displayed as a starting point when you first access the Diagnosis Picker screen (see Keeping a Diagnosis Category Open). If you want to choose a diagnosis code from a different category, tap Back to go back to the main Diagnosis Picker screen.
2. Select one of the options below:
   • Favorite Diagnoses: Select this option to view a flat list of your favorite codes and Search Terms.
   • Existing Problems: Select this option to view a flat list of the patient’s existing diagnoses. The five diagnoses that were used most recently are listed first. Or, if the patient has more than five existing diagnoses, tap the All Existing Problems item at the bottom of the list to view a complete list of all of the patient’s existing problems and then select problems from the longer list.
   • Latest Used Problems: This option displays a flat list of any problems you recently selected for this patient in the current ordering session. Pick one or more problems from the list.
   • Department Pickers: Scroll down to see all of the picker categories. Tap a category name to view the diagnosis codes, Diagnosis Macro Groups, or Search Terms within it. All of the lists above show the abbreviation “(HCC)” after the diagnosis description if a diagnosis code is designated as an HCC driver, meaning that it drives the revenue up in capitated Medicare Advantage plans. You can swipe right to left on an HCC diagnosis to expose the HCC button, and then tap the button to view the HCC description, the HCC category, and the Risk Adjustment Factor.

Please note that diagnosis codes are updated each year. As a result, a code that was included on your Favorite Diagnoses or Department Pickers list in the past may be inactive today. Inactive codes cannot be added as new problems. Inactive codes are removed from the Department Pickers list, but do remain on your Favorite Diagnoses list. To distinguish them from active codes, they are shown on the Favorite Diagnoses list with a Search icon and the text in light gray:. To find an active code with a similar description, select the inactive code. The description from the inactive code is placed in the Search field as a starting point, and a search is immediately executed. You can review the results and select a match, or change the search term and execute a new search. See Selecting Diagnoses Using the Search Option for more information on searching.

3. Select the diagnosis that you want.
   • If you select a non-specific diagnosis, you may have access to the Refine feature, in order to make the selected diagnosis as specific as possible. See Refining Non-Specific Diagnoses.
   • If you are entering a charge transaction and you select a diagnosis that has associated secondary diagnoses, you may be prompted to select a secondary diagnosis. See Selecting Secondary Diagnosis Codes.
4. The number of diagnoses that you are allowed to choose depends on your starting point. For example:
   • If you are entering a charge transaction, you are allowed to select one or more individual diagnoses or diagnosis macro groups. As you select each diagnosis or diagnosis macro group, a checkmark appears next to it. Select Done when you are finished choosing diagnoses. The main Charge Transaction screen is displayed, with all the codes that you selected shown on it. If you select a diagnosis macro group, the diagnoses contained in the group are listed individually.
   • If you are entering a clinical note, you are allowed to select more than one diagnosis or diagnosis macro group. As you select each individual diagnosis or diagnosis macro group, it is added to the A/P tab. If you select a diagnosis macro group, the diagnoses contained in the group are listed on the A/P tab individually.
   • If you are entering an order, you may select only one individual diagnosis (diagnosis macro groups are not displayed and so cannot be selected). After you select a diagnosis, the Order Details screen is displayed with the diagnosis that you selected shown on it.
   • If you are adding a patient problem directly in the Problem List module, you can select one individual diagnosis, or one diagnosis macro group. After you select an item, the Problem Detail screen is displayed, with the diagnosis or the diagnosis macro group that you selected shown on it. If you select a diagnosis macro group, then after you save the tap Save on the Problem Detail screen, each problem in the group is added as an individual item to the patient’s problem list.

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Keeping a Diagnosis Category Open

You may select one category on the Diagnosis Picker screen to keep open (either the Favorite Diagnoses list, one Department Pickers category, or the patient’s full Existing Problems list), so that when you first access the Diagnosis Picker screen, that category is automatically selected and the contents are displayed as a starting point. You can still navigate to another category, but the selected category is always your starting point. You may also deselect the “kept open” category, or select a different category to keep open, at any time. To select a category to keep open:

1. Start the process for entering a diagnosis on a charge transaction, an order, or a note, or directly in the Problem List module. The Diagnosis Picker screen is displayed.
2. Select the item that you want to keep open: either the Favorite Diagnoses list, one of the Picker categories, or the patient’s full Existing Problems list.
3. Once you are viewing the contents of the item that you want to keep open, tap Keep Open at the bottom right of the screen.
4. Select Done in the upper right corner of the screen. The category is now the one item that is kept open when you first access the Diagnosis Picker screen.

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To change the category that is kept open

1. Start the process for entering a diagnosis on a charge transaction, an order, or a note, or directly in the Problem List module. The Diagnosis Picker screen is displayed. The currently “kept open” category is displayed.
2. Navigate to the new category that you want to keep open, either the Favorite Diagnoses list, a different Picker category, or the patient’s full Existing Problems list.
3. Once you are viewing the contents of the item that you want to keep open, select Keep Open at the bottom right of the screen.
4. Select Done in the upper right corner of the screen. The new item automatically becomes the one category that is kept open (you do not have to “clear” the prior category).

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To clear the category that is kept open, so that no category is kept open

1. Start the process for entering a diagnosis on a charge transaction, an order, or a note, or directly in the Problem List module. The Diagnosis Picker screen is displayed. The currently “kept open” category is displayed.
2. Select Keep Closed at the bottom right of the screen.
3. Select Done in the upper right corner of the screen. The category is “cleared” and no category is kept open from this point forward.

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Adding or Removing Items to/from your Favorite Diagnoses List

When looking at the Existing Problems list, the Department Pickers list, or the results of a diagnosis Search, you can add or remove diagnosis codes or search terms that you see on these lists to or from your Favorite Diagnoses list. After you add one or more codes/search terms to your favorites, you can then quickly select those items when entering diagnoses for your patients. You can add up to one hundred diagnosis codes to the Favorite Diagnoses list. To add a code or search term to your Favorite Diagnoses list:

1. Start the process for entering a diagnosis on a charge transaction, an order, or a note, or directly in the Problem List module. The Diagnosis Picker screen is displayed.
2. Select or use any of the options below:
   • Search (perform a search for a diagnosis code, so that a list of results is shown)
   • Department Pickers list
   • Existing Problems list Notice that in all of these options, there is a Favorites icon ( or to the left of every diagnosis code. A gray star indicates that the diagnosis code is not yet on your Favorite Diagnoses list, while a gold star indicates that the code is already on your Favorite Diagnoses list. Although search terms do not show the gold or gray stars, they can still be added or removed to/from your favorites list via the Favorite and Unfavorite buttons (see next step).

3. Identify the diagnosis code or search term that you want to add to your favorites list and then take either of the actions below: For diagnosis codes, the Favorites icon changes to gold and the code is added to your favorites list. For search terms, the term is simply added to your favorites list.

• For diagnosis codes or search terms, swipe right to left on the diagnosis code or search term’s row to expose the Favorite button, and then tap the button. (If swiping exposes an Unfavorite button, it means that the item is already on your favorites list.)
• For diagnosis codes, tap the gray Favorites icon to the left of the diagnosis code, or

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To remove a code or search term from your Favorite Diagnoses list

1. Start the process for entering a diagnosis on a charge transaction, a note, or order, or directly in the Problem List module. The Diagnosis Picker screen is displayed.
2. Select the Favorite Diagnoses option.
3. Identify the diagnosis code or search term that you want to remove from your favorites list and then take either of the actions below:

• For diagnosis codes, tap the gold Favorites icon to the left of the diagnosis code, or
• For either diagnosis codes or search terms, swipe right to left on the diagnosis code or search term’s row to expose the Unfavorite button, and then tap the button. For diagnosis codes, Favorites icon changes to gray to indicate that you have chosen to remove it. For search terms, the search term name changes to light gray text. Once you tap Done to exit the Diagnosis Picker screen, the code or search term is removed from your favorites list.

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Selecting Diagnoses Using the Search Option

If you cannot find the code you want in the Favorite Diagnoses, Department Pickers, or Existing Problems list options, you can use the Search option to search the entire master list of diagnosis codes. The Search option is available when adding a diagnosis on a charge transaction, order, or clinical note, or when adding one directly in the problem list module. When searching for a diagnosis, you can enter any of the following into the Search field:

• A partial or complete diagnosis description
• A partial or complete ICD-10 code
• A partial or complete ICD-9 code (If you enter an ICD-9 code, the corresponding ICD-10 codes are returned in the results. This can be very helpful if you are not yet familiar with ICD-10 codes.)
• A partial or complete SNOMED CT® code The application uses a medical vocabulary called Intelligent Medical Objects (IMO®) to provide an alternate set of diagnosis descriptions in the search results. IMO is a patient-centric terminology database that is licensed through Commure Pro and it provides extensive mappings of disease states to ICD-9 or ICD-10 codes and any applicable HCC codes. Search queries involving IMO terms are limited to 100 results.

To search for a diagnosis code, follow these steps:

1. Start the process for entering a diagnosis on a charge transaction, an order, a note, or directly in the Problem List module. The Diagnosis Picker screen appears.
2. Tap into the Search field at the top of the Diagnosis Picker screen.
3. Type a diagnosis code or a phrase in the Search field, and then select the Search button on the virtual keyboard.

A search of the entire master diagnosis list is now performed, and the potential matches are displayed in a list. The list shows you the most relevant diagnoses first, based on the search term that you used. There are several options available to help you find the diagnosis that you want from the list of results:

• You can change the order in which the diagnoses are listed, so that they are instead sorted numerically by charge code, or alphabetically by description.
• You can use filters to narrow the results down to a more concise list.
• If this is an item that you search for frequently, you can save your search as a Search Term so that you can re-use later.
• If you select a non-specific diagnosis from the results, you may have access to the Refine feature, which walks you through selecting a series of attributes from various categories, in order to make the selected diagnosis as specific as possible. For instructions on any of these features, see Additional Search and Filtering Features for Diagnoses.

Just above the list of matches, a free text entry is also displayed: Free Text: “[your phrase].” This may be the only item if no matches were found. See Entering Diagnoses as Free Text for more information. The abbreviation “(HCC)” is displayed after the diagnosis description if a diagnosis code is designated as an HCC code. You can swipe right to left on an HCC diagnosis to expose the HCC button, and then tap the button to view the HCC description, the HCC category, and the Risk Adjustment Factor.

4. When you find the diagnosis that you want on the results list, tap on it to select it.
5. (Optional) You can clear the text in the Search field and perform additional searches as necessary (repeat Steps 2 - 4). Or, if you cannot find the diagnosis you want in the search results, see Entering Diagnoses as Free Text. The number of diagnoses that you are allowed to choose from the search results depends on your starting point. For example:
   • If you are entering a charge transaction, you are allowed to select more than one diagnosis from the search results, or to perform multiple searches and select multiple diagnoses. As you select each diagnosis, a checkmark appears next to it. Select Done when you are finished choosing diagnoses. The main Charge Transaction screen is displayed, with the diagnoses that you selected shown on it.
   • If you are entering a clinical note, you are allowed to select more than one diagnosis from the search results. Each diagnosis is added to the A/P tab as you select it.
   • If you are entering an order, you may select only one diagnosis from the search results. After you select it, you may be presented with one or both of the pop-up options below:
   • Rule Out: Select this option if the problem should be used for this order only. The words “Rule Out” will precede the problem description in all displays and print-outs for this order.
   • Add to Problem List: Select this option if the problem should be used for this order, and also automatically added to the patient’s problem list. The Order Details screen is displayed with the diagnosis that you selected shown on it.

• If you are adding a patient problem directly in the Problem List module, you may select only one diagnosis from the search results. After you select it, the Problem Detail screen is displayed, with the diagnosis that you selected shown on it.

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Additional Search and Filtering Features for Diagnoses

After typing some numbers or a phrase into the Search field, a list of potential matching diagnosis codes is displayed. Sometimes this list can be quite long, so there are several options available to help you find the specific diagnosis that you want:

• You can use the Filter option to sort the list of matches in a specific order, or to narrow the matches down to a concise list. You apply the Filter options before selecting a diagnosis. See Using the Filter Option for Diagnoses.
• If you select a diagnosis from the list that is not very specific, you can use the Refine feature. The Refine feature is used after selecting a diagnosis. This feature walks you through selecting a series of attributes from various categories, in order to make the selected diagnosis as specific as possible. See Refining Non-Specific Diagnoses.
• You can save a search that you performed as a Search Term, so that you can re-use it later. If you used the Filter option during your search, any sorting or filtering that you applied are also saved as part of the search term. Search terms are added to you Favorite Diagnoses list, so that you can find them quickly. See Saving a Diagnosis Search as a Search Term on Your Favorites List.

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Using the Filter Option for Diagnoses

After typing some numbers or a phrase into the Search field, a list of potential matching diagnosis codes is displayed. You can then use the Filter option to either sort or filter the list of matches, to help find the specific code that you want. For example, you can sort the list of matches numerically by diagnosis code, or alphabetically by description. Or, you can use filters to narrow the results down to a more concise list. By default, the application automatically applies the Age and Gender filters, so that the result list shows only those diagnoses that are appropriate for the patient, based on their age and gender. However, you can turn off these filters if necessary. For example, you might turn off the gender filter when searching for a diagnosis for a patient who is transitioning from one gender to another.

1. Perform a search for a diagnosis by typing some numbers or a phrase in the Search field on the Diagnosis Picker screen. A list of potential matches is displayed.
2. Tap either the Filter button at the top of the screen, or the Filters applied button in the middle of the screen.

The Filter screen opens.

3. To change the sort order:
   • In the Sort Type field, select Default (Rank), Description, or Code. The Default (Rank) option sorts the diagnoses so that the most relevant ones are shown first.
   • In the Sort Direction field, select Default, Ascending, or Descending. The list of potential matches will be sorted in the desired manner. All future searches for diagnosis codes will be sorted in this same manner, unless you change it using the same steps as above.
4. To apply a filter select one or more of the items below. You may use any combination of these filters (some filters may not be available).

• FILTER TERMS: A series of filters are automatically created based on commonly used terms found in the results. Tap Add to view and select one or more of these filters. Only those diagnoses containing the specific term(s) that you selected will be shown in the search results.
  • SPECIALTY: Select this item to see a list of specialty filters. Only those diagnoses that are used by the specialty that you selected will be shown in the search results.
  • IMO FILTERS: Select this item to see a list of IMO classifications by disease for the terms by which you are searching. For example, when searching for diabetes, you might see filters for trimester classifications for gestational diabetes.
  • PATIENT DEMOGRAHICS: Both the Patient Gender and Patient Age filters are turned on by default (note the checkmark next to each), indicating that only diagnoses for the patient’s listed gender and age are shown. To turn off either of these filters, select the filter, and the checkmark is removed.

5. Tap Done on the Filters screen. The Diagnosis Picker screen with the search results is redisplayed. It shows only those results that match the criteria you selected on the Filter screen.

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Saving a Diagnosis Search as a Search Term on Your Favorites List

If you find that you are searching for the same diagnosis over and over again, you can save your search as a Search Term, so that you can re-use later. In addition, if you used the Filter option when performing your search (as described in Using the Filter Option for Diagnoses), you can save that search criteria as part of your Search Term. The Search Term is added to your Favorite Diagnoses list for future use. It is preceded by a Search icon so that you can distinguish it from regular diagnosis codes:. If at a later date you decide you no longer need the Search Term, you can easily remove it. To save a diagnosis search as a Search Term:

1. Perform a search for a diagnosis by typing some numbers or a phrase in the Search field on the Diagnosis Picker screen. A list of potential matches is displayed.
2. (Optional) Use the Filter button to further narrow the search results to a more concise list, as described in Using the Filter Option for Diagnoses. The Diagnosis Picker screen with the search results is redisplayed. It shows only those results that match the criteria you selected on the Filter screen.
3. Tap Save Search in the lower right corner of the search results screen.
4. In the Add Favorite dialog box, give the Search Term a name (the phrase you used in Step 1 is the default name), and then tap OK. The Search Term is added to your Favorite Diagnoses list for future use, and is preceded by a Search icon, as in this example:

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To remove a Search Term from your Favorite Diagnoses list

1. Start the process for entering a diagnosis on a charge transaction, a note, or order, or directly in the Problem List module. The Diagnosis Picker screen is displayed.
2. Select the Favorite Diagnoses option.
3. Identify the Search Term that you want to remove from your favorites list and swipe right to left on its row to expose the Unfavorite button
4. Tap Unfavorite The Search Term changes to light gray to indicate that you have chosen to remove it. Once you tap Done to exit the Diagnosis Picker screen, the Search Term is removed from your favorites list.

You can also remove a Search Term from your Favorite Diagnoses list immediately after using it, as follows:

1. Start the process for entering a diagnosis on a charge transaction, a note, or order, or directly in the Problem List module. The Diagnosis Picker screen is displayed.
2. Select the Favorite Diagnoses option.
3. Tap on any Search Term as if you were going to use it. The search is executed.
4. Tap Remove Saved Search at the bottom of the screen. The Search Term is immediately removed from your Favorite Diagnoses list.
5. Tap Back to return to the Diagnosis Picker screen.

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Refining Non-Specific Diagnoses

If you select a non-specific diagnosis (from the Favorites, Existing, or Department Pickers list, or by Searching for it), you may have access to the Refine feature. This feature walks you through selecting a series of attributes from various categories, in order to make the selected diagnosis as specific as possible. Depending on how your user profile is configured:

• In the Charges, Clinical Notes, and Problem List modules, you may be required to use the Refine feature, or you may be allowed to select non-specific diagnoses without any refinement.
• In the Orders module, the Refine feature is always available as an optional feature. To use the Refine feature:

1. Review the diagnoses on the Favorites, Existing, or Department Pickers list, or perform a Search for a diagnosis.
2. Review the list of diagnosis codes and determine your next step:
   • In the Charges, Clinical Notes, and Problem List modules, there is no indication of which diagnoses are specific versus non-specific. Tap on the diagnosis code you want from the Favorites, Existing or Department Pickers list, or from the Search results. If the diagnosis is non-specific and you user profile requires that you refine it, then the Diagnosis Filters screen appears automatically. (If your user profile does not require that you refine it, the diagnosis is simply selected as is.)
   • In the Orders module, the Refine feature is not available for diagnoses on the Favorites, Existing or Department Pickers list. If you perform a Search for a diagnosis, then any non-specific diagnoses in the search results show a Refine button to the right of the diagnosis description, while all other diagnoses do not show any button. If you want to make one of these diagnoses more specific, tap the Refine button to open the Diagnosis Filters screen. (Or, if you want to select the non-specific diagnosis as is, just tap the diagnosis description). The Diagnosis Filters screen is displayed and shows a series of categories (such as type, a complication, or a severity), with a list of attributes in each category.
3. Select an attribute from the first or any other category. The next applicable category is automatically displayed.
4. Continue selecting attributes from each category as it is presented to you. As you select attributes, some categories may no longer apply and are disabled (grayed out). You can undo all of your previous selections and start over again by tapping Clear at the top right of the screen. Once the diagnosis is detailed enough, the Diagnosis Filters screen closes and the refined diagnosis is automatically added to the charge, note, order, or problem list.

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Entering Diagnoses as Free Text

If you cannot find the diagnosis that you want by looking in your Favorite Diagnoses, Department Pickers, or by performing a Search for it, you may be able to enter it as free text. This feature is available when adding a diagnosis on a charge transaction, order, or clinical note, or when adding one directly in the Problem List module. Your ability to enter free text problems in these options depends on the option you are using, and several settings in your user profile.

1. Start the process for entering a diagnosis on a charge transaction, an order, or a note, or directly in the Problem List module. The Diagnosis Picker screen appears.
2. Select the Search option and type a diagnosis description into the text field. As you type each character, a free text entry using that phrase is created and displayed below the Filters applied option, and above the search results, in the format: Free Text: “[your phrase].” For example:
3. Review the list of search results. If you do not see the diagnosis you want, then select the Free Text: “[your phrase]” option. A checkmark appears next to the free text entry.
4. Your next step depends on your starting point. For example:
   • If you are entering a charge transaction, select Done. The main Charge Transaction screen is displayed, with the free text diagnosis shown on it.
   • If you are entering a clinical note, the free text diagnosis is added to the A/P tab.
   • If you are entering an order, after you select the free text entry, you may be presented with one or both of the pop-up options below:
   • Rule Out: Select this option to enter a free text problem that will be used for this order only. Just type the free text problem into the text field and select Done. The words “Rule Out” will precede the problem description in all displays and print-outs for this order.
   • Add to Problem List: Select this option to enter a free text problem that will be used for this order, and also automatically added to the patient’s problem list. Type the free text problem into the text field and select Done. The Order Details screen is displayed with the free text diagnosis shown on it.

• If you are adding a patient problem directly in the Problem List module, select Done. The Problem Detail screen is displayed, with the free text diagnosis shown on it.

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Editing or Resolving a Problem on the Problem List

In the Problem List module you can edit a problem to update its details. For example, you might note that a problem has been resolved by changing the Status and adding a Resolved date. To update the details of a problem, follow these steps:

1. In the Problem List module, on the Problem List Summary, review the patient’s problems and select the problem that you want to edit or resolve. The Problem Detail screen is displayed.
2. Tap Edit in the top right corner of the screen.
3. Edit the appropriate information (depending on your system configuration, not all fields may be editable).
   • Onset: Enter the date of onset for the problem.
   • Diagnosed: Enter the date the patient was diagnosed with this problem.
   • Resolved: Enter the date the problem was resolved. When you enter a date here, the Status field is automatically changed to Resolved.
   • Last Used: This read-only field shows the date the problem was last used on a charge, note, or order (or when it was initially created if it has not yet been used on a charge, note, or order).
   • Type: Select the type of problem. Your choices are Acute and Chronic. The default is Acute.
   • Status: Select an item that describes the current status of the problem, such as Active, Inactive, Resolved, or Cancelled. The default is Active.
   • Codes: This read-only field shows all of the code designations for this problem, according to the various diagnosis classification systems (ICD-9, ICD-10, and Snomed).
   • HCC: This read-only field indicates whether the diagnosis is an HCC driver, meaning that it drives the revenue up in capitated Medicare Advantage plans.
   • Created: This read-only field shows the date the problem was initially created.
   • Source: This read-only field shows hospital or practice from which this information was derived. If the problem was entered directly in the Commure Pro system, the source is “MANUALLYADDED.” This field is present only if your organization has implemented Commure Pro’s HIE option. See Viewing the Source of Clinical Data (HIE).
4. Tap Save to save the changes and return to the Problem List Summary.

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Deleting a Problem from the Problem List

If you find that a problem is incorrect for a patient, you can delete it from the patient’s problem list. This is different from marking a problem as resolved, which indicates that the problem was valid for a certain period of time, but is no longer an issue for the patient (see Editing or Resolving a Problem on the Problem List for instructions on how to mark a problem as resolved).

1. In the Problem List module, on the Problem List Summary, review the patient’s problems and identify the problem that you want to delete.
2. Touch the problem and swipe to the left to expose the Delete button .
3. Tap Delete . The problem is removed from the Problem List Summary, as well as from the EXISTNG PROBLEMS list on the Diagnosis Picker screen.