Entering Patient Problems

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 can be entered in Commure Pro (in both Classic and Revenue Reports mode) as the diagnosis on a completed charge transaction. (Problems associated with draft charges are not added to the Problem List.)
• Problems can be entered in Commure Pro (in Classic mode only) as part of a completed clinical note. (Problems associated with draft notes are not added to the Problem List.)
• Problems can be entered in Commure Pro (in Classic mode only) as the reason for an order. (Problems entered as a “rule out” reason on an order are not added to the Problem List.)
• Problems can be entered or modified in Commure Pro (in both Classic and Revenue Reports mode), independent of charges/notes/orders. In Classic mode, this is done via the Problems display option on the Patient List tab.
• Problems can be entered in an external system and then automatically passed to the Commure Pro system via any of the methods below:
  • Problems can be passed from a Cerner^® system to Commure Pro when entering charges via the Commure Pro-Cerner Charge Capture app.
  • Problems can be passed from an external system to Commure Pro when accessing Commure Pro via custom link from the other system.
  • Problems can be automatically interfaced from an external system to Commure Pro.
  In all of the cases above, the Commure Pro system can accept either the ICD-10 code or the Intelligent Medical Objects (IMO^®) term. These optional features require configuration by Commure Pro services, and may function differently at each site, depending on the organization’s requirements.

This chapter reviews how to enter problems in the Commure Pro system in Classic mode, either as part of a charge transaction or clinical note, or as an independent entity. No matter which workflow you use to enter the problem, there are several different ways to find and select the diagnosis that you want, each of which is also described in this chapter. (For information on how to enter a diagnosis as part of an order, see Adding a Reason to a New Order, as that workflow is different than described here.)

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Entering a New Problem (Without a Charge or Note)

To enter a new problem for a patient, independent of charges or notes, follow these steps:

1. Select a patient on the Patient List tab, or click on the Details icon from another option.
2. Use one of the following to open the Add Problem window:
   • Click the Add button next to the Problems option in the center column.
   Select the Problems option to display any problems already associated with the patient in the summary Problem List window. You can click on any problem to see the details about it.
   • Click the Actions button in the upper right corner of the Patient Data Display, and then select Add Problem from the drop-down list.
   The Add Problem dialog box appears.
3. Click the Find Problem button. The Problem Selection window is displayed. In the Problem Selection window, you can Search for the diagnosis from the master list of diagnosis codes, select it from the Favorites or Department category, or enter it as free text. See the topics below for instructions.
   • Selecting Diagnoses Using the Search Option
   • Selecting Diagnoses From the Favorites or Department Categories
   • Entering Diagnoses as Free Text
   After selecting an individual diagnosis, it is displayed in the Add Problem dialog box after the word Problem. If you select a Diagnosis Macro Group, all of the diagnoses in the group are displayed. The ICD-10 code and description are displayed, as well as the Snomed code (if applicable).
4. Enter additional attributes for the problem. The list of attributes can vary by organization; those on your system may not be the same as those listed here. Please note that you selected a Diagnosis Macro Group, all of the attributes below are applied to all of the diagnoses in the group.
   • Type: Select the type of problem. Your choices are Acute and Chronic. The default is Acute.
   • Status: Select the current status of the problem. Your choices are Active, Inactive, or Resolved. The default is Active.
   • Onset: Enter the date and time of onset for this problem, if known. If left blank, the current date and time is automatically saved as the date of onset.
   • Diagnosed: Enter the date and time that this problem was diagnosed, if known.
   • Resolved: Enter the date and time this problem was resolved (if known, or if resolved).
   • Last Used: This field represents the date and time this problem was last used for this patient. If left blank, the current date and time is automatically saved as the last used date.
5. Click the Save button to save this problem, or click Cancel to close the window without saving. 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. In addition, when a new problem is saved, it is associated with a specific patient visit. The visit associated with the problem is stored in the database, but is not visible in the application. The following rules are applied:
   • If the patient visit selected on the Patient List when the user starts the Add Problem workflow is an InFacility visit, the patient’s current InFacility visit is associated with the problem. In most cases, the current InFacility visit is the most recent visit, but there are some exceptions. For example, if the most recent visit is discharged and there is an older visit that is not discharged with the same account number, then in this case, the older non-discharged visit is the current InFacility visit.
   • If the patient visit selected on the Patient List when the user starts the Add Problem workflow is a non-InFacility visit, that non-InFacility visit is associated with the problem.

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Selecting Diagnoses from the Patient’s List of Existing Diagnoses

You can select a diagnosis from the patient’s list of Existing diagnoses when:

• Adding a diagnosis on a clinical note (if you are using one of the default progress note templates included with NoteWriter)
• Adding a diagnosis on a charge transaction View a How-To Video on Selecting Diagnosis Codes on the Charge Transaction screen (including selecting from the Existing list).

When adding a diagnosis on a charge transaction or clinical note, the Existing category is displayed at the top of the list DIAGNOSES section.

1. Click on the Existing category to view a list of diagnosis codes that have been previously used for a particular patient, pulled from the patient’s problem list history (see Entering Patient Problems for an explanation of how diagnoses get added to a patient’s problem list history).
   • The date that each diagnosis was last used is displayed, and the diagnoses that were used most recently are listed first.
   • If a gray HCC icon is displayed to the right of a diagnosis description, it means that the code is designated as an HCC driver.
   • If a red HCC icon is displayed to the right of a diagnosis description, it means that the HCC diagnosis has not been used for that patient on a charge or clinical note within the current calendar year.
2. (Optional) You can click the My List link (it turns orange: My List) to filter the list down to only those diagnoses that you have used yourself for this patient. This includes diagnoses that you entered on a charge or clinical note, that you entered directly in the Problem List module, or that were passed via a link that you used to access Commure Pro from an external system. Click the My List link a second time to remove the filtering and view all of the patient’s existing diagnoses. Please note that the My List link is “sticky” — once you select it, it remains selected for all future charge transactions and notes until you unselect it.
3. Use any of the methods below to select diagnoses from the Existing list:
   • To select one or more existing diagnosis, just click on the individual diagnoses that you want.
   • To quickly select all of the patient’s existing diagnoses, click the Add All link (available only if enabled in your user profile).
   • To quickly select all of the existing diagnoses that you have used in the past, first click the My List link to filter the list, and then click the Add All link to select all the diagnoses in the filtered list.
   • Since diagnosis codes are updated each year, a code that was included on a patient’s Existing list in the past, may be inactive today. Inactive codes cannot be used on new charges or clinical notes. To distinguish them from active codes, they are shown on the Existing list with a Search icon, the code struck through, and the text in light gray.
   To find an active code with a similar description, click on the inactive code. A search is immediately executed using the inactive code’s description. See Selecting Diagnoses Using the Search Option for more information on searching. The diagnoses are then added to the Selected Codes section on the right side of the Charge Transaction screen (for a charge transaction) or to the section of the note where you are currently working (for a clinical note). When entering diagnoses on clinical notes, since much of the pre-operative diagnosis is usually included in a post-operative diagnosis, when a pre-operative diagnosis is selected, the diagnosis is added to both the pre-operative diagnosis and post-operative diagnosis lists to speed data collection. If a post-operative diagnosis is selected, the diagnoses is added only to the post-operative diagnosis list.

You can also delete a diagnosis code from the patient’s Existing list if you feel that it is no longer appropriate. For example, you may want to delete any old ICD-9 codes from the patient’s Existing list. Or if a diagnosis on the Existing list were incorrect, you could delete it.

• To delete an existing diagnosis, hover your mouse cursor over the existing diagnosis to expose the Delete button to the right of the diagnosis, and then click it.

Show Settings that control this feature

• Admin - User - Charge Capture - Prompt User to Add All Existing Diagnoses

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Selecting Diagnoses From the Favorites or Department Categories

You can select a diagnosis from the Favorites or Department category when:

• Adding a diagnosis independent of a charge or note
• Adding a diagnosis on a clinical note
• Adding a diagnosis on a charge transaction

View a How-To Video on Selecting Diagnosis Codes on the Charge Transaction screen (including selecting from the Favorites or Department categories). The two categories differ as follows:

• The Favorites category is available only if your administrator has enabled it for you. It contains those diagnoses that you have personally marked as favorites. This category may contain a simple list of codes, or you may have organized them into subcategories.
• The Department category contains the diagnoses that your administrator has deemed useful to all members of your department and these are typically organized into subcategories. For example, diagnosis categories might include Abnormal Findings, Cardiovascular Disease, or Gastroenterology.

In addition to diagnosis codes, the Favorites and Department categories can also contain the following items, if you or your department administrator have added them to those categories:

• Diagnosis Search Terms, which are preceded by a search icon so that you can distinguish them from regular diagnosis codes: A diagnosis search term is a partial code or phrase that immediately executes a search. For example, if you click 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, clicking on a Search Term of “R07” would immediately show all diagnoses containing those letters and numbers, such as R07.0, R07.1, R07.81, and so on. Diagnosis Macro Groups, which are preceded by a gears icon so that you can distinguish them from regular diagnosis codes: Diagnosis macro groups are a time-saving feature that allow you to enter the entire group related diagnosis codes with a single mouse click. 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 Selected Codes section. Before selecting a diagnosis macro group, you can hover your mouse cursor over it to expose the Information icon , and then click the icon to see all of the items that are included within the macro.

To select an item from the Favorites or Department category:

1. In the DIAGNOSES section, click on the Favorites or Department category to expand it (if it is not already expanded). The category expands to show you the contents. This may be a list of subcategories, or a list of actual diagnosis codes, search terms, or diagnosis macro groups.
2. Continue to drill down through the subcategories until you see the diagnosis code, search term, or macro group that you want.
   • If a diagnosis code in the Favorites or Department category is designated as an HCC code, an HCC icon displays to the right of the diagnosis description. Hover your mouse cursor over the icon to view the HCC description, HCC category, and the Risk Adjustment Factor.
3. When you see the specific item you want, click on it.
   • If you select an individual diagnosis code or a diagnosis macro group…
   o and you are entering a charge transaction, then the individual code, or all of the codes in the diagnosis macro group, are added to the Selected Codes section on the right side of the screen. o and you are entering a clinical note, then the individual code, or all of the codes in the diagnosis macro group, are added to the section of the note where you are currently working. o and you are adding a patient problem independent of a charge or note, then the Add Problem screen is displayed and shows either the individual diagnosis, or all of the diagnoses in diagnosis macro group.
   • If you select a diagnosis search term, a Search for that term is immediately executed. See Selecting Diagnoses Using the Search Option for more information.
   • Since diagnosis codes are updated each year, a code that was included on your Favorites list in the past, may be inactive today. Inactive codes cannot be used on new charges or clinical notes. To distinguish them from active codes, they are shown on the Favorites list with a Search icon, the code struck through, and the text in light gray:
   To find an active code with a similar description, click on the inactive code. A search is immediately executed using the inactive code’s description. See Selecting Diagnoses Using the Search Option for more information on searching. (Inactive codes are not shown in the Department category or in search results.)
4. Depending on your starting point, you may now be able to select additional diagnosis codes:
   • If you are entering a charge transaction or a clinical note, you are allowed to select more than one diagnosis code or diagnosis macro group.
   • If you are adding a patient problem independent of a charge or note, you can select only one individual diagnosis, or one diagnosis macro group.

Show Settings that control this feature

• Admin - User - Problem List - Show Diagnosis Favorites Tab

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Selecting Diagnoses Using the Search Option

Use the Search option to search for a diagnosis from the complete list of diagnoses. You can use the Search feature when:

• Adding a diagnosis independent of a charge or note
• Adding a diagnosis on a clinical note
• Adding a diagnosis on a charge transaction View a How-To Video on Selecting Diagnosis Codes on the Charge Transaction screen (including using the Search option).

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 diagnosis Search field 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 Proand it provides extensive mappings of disease states to ICD-9 or ICD-10 codes and any applicable HCC codes. Search queries involving IMO terms show the most relevant 100 results based on their IMO ranking. When searching for a diagnosis:

• A search will return diagnoses from the master list of diagnoses as well as from the patient’s Existing list of problems.
• If a diagnosis is displayed at the top of the results list in bold type, it means that the diagnosis is already on the patient’s Existing list. The date it was last used on a charge transaction is also displayed in parenthesis.
• If a gray HCC icon is displayed to the right of the of a diagnosis in the results, it means that the code is designated as an HCC driver. HCC codes drive up the revenue in capitated Medicare Advantage plans. Hover your mouse cursor over the icon to view the HCC description, the HCC category, and the Risk Adjustment Factor.
• If a red HCC icon is displayed to the right of a diagnosis in the results list (and the diagnosis is also displayed in bold type), it means that the diagnosis is already on the patient’s Existing list and that it has not been used for that patient on a charge or clinical note within the current calendar year. The date it was last used is displayed in red text.
• If a NOS Alert icon is displayed to the right of a diagnosis, it means that the code has a “Not Otherwise Specified” designation. You can still select the diagnosis; it is simply a visual cue to remind you that you should select a more specific diagnosis, if possible. This warning icon is visible only if enabled system-wide.

To search for a diagnosis code, follow these steps:

1. In the DIAGNOSES section, click into the diagnosis Search field and type a partial or complete diagnosis code or a description. (Or, you could select a Search Term from the Favorites or Department categories, see Selecting Diagnoses From the Favorites or Department Categories.) As you are typing, any diagnoses that match what you type are displayed. The number of characters that you must enter to trigger these matching search results is configurable (the default is two characters, contact your Commure Pro representative to change this).
   • If you enter a diagnosis code that has a single exact match, it is automatically selected for you.
   • If you enter a diagnosis code or description that does not have a single exact match, then a list of potential matches is displayed. The list shows you the most relevant diagnoses first, based on the search term that you used. Any diagnoses in the results that are also on the patient’s Existing list are shown in bold text at the top of the list, along with the date they were last 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 diagnosis code, or alphabetically by description.
   • You can use Filter button (located at the top right of the search results) 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 be required to use the automatic 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.
   • If you select a diagnosis that should be accompanied by one or more secondary diagnoses for full and accurate billing and documentation, you are alerted to that fact.
   For instructions on any of these features, see Additional Search and Filtering Features for Diagnoses.
2. Select the diagnosis that you want from the search results, 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. As you select each diagnosis, it is added to the Selected Codes section on the right side of the screen.
   • If you are entering a clinical note, you are allowed to select more than one diagnosis. As you select each diagnosis, it is added to the section of the note where you are currently working.
   • If you are adding a patient problem independent of a charge or note, you may select only one diagnosis. After you select it, the Add Problem screen is displayed, with the diagnosis that you selected shown on it.
3. (Optional) Perform searches for additional diagnoses as necessary:
   1. Click X in the Search field to clear the prior search phrase.
   2. Repeat Step 1 through Step 2.

Show Settings that control this feature

• Admin - Institution - Problem List - Display alert on problems flagged as NOS

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Additional Search and Filtering Features for Diagnoses

After typing some numbers or a phrase into the diagnosis Search field (or after selecting a Search Term from the Favorites or Department categories), 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 Sort options to change the sort order for the list of potential matches in the Search Results section. See Changing the Sort Order for the Diagnosis Search Results.
• You can use the Filter options 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 Using the Refine Option for Non-Specific Diagnoses.
• If you select a diagnosis that should be accompanied by one or more secondary diagnoses, for full and accurate billing and documentation, you are alerted to that fact. See Selecting Secondary Diagnosis Codes.
• 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 options during your search, any filtering that you applied is 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 Creating a New Search Term for the Diagnosis Favorites Category.

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Changing the Sort Order for the Diagnosis Search Results

After typing some numbers or a phrase into the diagnosis Search field (or after selecting a Search Term from the Favorites or Department categories), a list of potential matching diagnosis codes is displayed in the Search Results. If the list of matches is long, you can change the way it is sorted, to help you find the code you want more easily.

1. In the DIAGNOSES section, click into the Search field and type a partial or complete code or a description. A list of potential matches is displayed in the Search Results.
2. Just below the Search field, select one of the Sort By options:
   • Default (the default): Sorts the diagnoses so that the most relevant ones are shown first.
   • Code: Sorts numerically by code, in ascending order.
   • Description: Sorts alphabetically by description, in alphabetic order.
   The diagnoses are sorted in the selected order.
3. To reverse the sort order, either click the Sort icon or click on the same sort option a second time (for example, click Description a second time to sort in reverse alphabetic order). You might do this if you knew the item you were looking for was near the end of the alphabet.

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Using the Filter Option for Diagnoses

After typing some numbers or a phrase into the diagnosis Search field (or after selecting a Search Term from the Favorites or Department categories), a list of potential matching diagnosis codes is displayed. You can then use the Filter button 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. In the DIAGNOSES section, click into the Search field and type a partial or complete code or a description. A list of potential matches is displayed.
2. Click the Filter button . A list of filter options opens to the right of the search results. Please note that once you click the Filter button to open the filter options, they will automatically open each time you perform a diagnosis search, until you click the Filter button again to close them.
3. Select any combination of the filters below (some filters may not be available).
   • Filters by Patient Demographics (Age and Gender): Both of these filters are turned on by default. To turn them off, click Delete to the right of the filter name under the Current Filters heading.
   • Filters by IMO Classification: You may see IMO classifications by disease for the terms by which you are searching. For example, when searching for diabetes, you would see filters for trimester classifications for gestational diabetes.
   • Filters by Common Terms: A series of filters are automatically created based on commonly used terms found in the results. Select any of these filters to view only those diagnoses containing a specific term.
   • Filters by Clinical Area: Select a Clinical Area filter to view only those diagnoses that are used by a specific specialty.
   As you select each filter, the search results are refreshed to show only those diagnoses that match the filter. In addition, the filter name is added to the list of selected filters under the Current Filters heading.
4. (Optional) To unselect a filter and expand the list of results again, click Delete to the right of the filter name.
5. Select a diagnosis from the filtered list of diagnoses.

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Using the Refine Option for Non-Specific Diagnoses

After typing some numbers or a phrase into the diagnosis Search field (or after selecting a Search Term from the Favorites or Department categories), a list of potential matching diagnosis codes is displayed in the Search Results section of the screen. If your user profile requires you to select a specific diagnosis, you will see the Non-Specific Diagnosis icon to the left of any diagnosis in the search results that is not specific enough. If you select a non-specific diagnosis from this list, the application walks you through selecting a series of attributes from various categories in order to make the diagnosis as specific as possible. This feature is available when:

• Adding a diagnosis on a charge transaction
• Adding a diagnosis on a clinical note
• Adding a diagnosis independent of a charge or note

To use the Refine feature:

1. In the DIAGNOSES section, click into the Search field and type a partial or complete code or a description.
2. Review the list of matching diagnosis codes and select one. If you select a non-specific diagnosis indicated by this icon, then one or more diagnosis filter dialog boxes are automatically displayed. Each dialog box shows a category (such as type, a complication, or a severity) with a list of attributes. (If you select a diagnosis that does not have this icon, the diagnosis is simply selected as is, and you are not required to complete the remaining steps.)
3. Select an attribute from each category as it is presented to you. After you select an attribute from a category, the application automatically displays the next category, so that you can quickly step through the process. However, you are not required to step through the categories in the order in which they are presented; you can click on any category in any order. The currently selected category is in bold text and has an Expand icon next to it: As you select attributes, some categories may no longer apply and are disabled (grayed out).
4. (Optional) You can undo a previous selection for a category by clicking the Undo icon to the left of that category’s name: Once the diagnosis is detailed enough, the dialog box closes and the refined diagnosis is automatically selected.

   Show Settings that control this feature

   • Admin - User - Problem List - Allow non-specific diagnoses

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Selecting Secondary Diagnosis Codes

View a How-To Video on Modifying the Selected Diagnosis Codes (including selecting secondary diagnosis codes). When entering a charge transaction, after you select a diagnosis (from the Existing, Favorites, or Department categories, or by Searching for it), the appropriate diagnosis code is added to the Selected Codes area. In some cases, when you select a primary diagnoses, you should also select one or more secondary diagnoses, for full and accurate billing and documentation. The application always alerts you when one or more secondary diagnoses may be applicable, based on a setting in your user profile. Please note that this feature is available only when adding a diagnosis on a charge transaction. For example, when you select “Obesity, diabetes, and hypertension syndrome” from the IMO vocabulary, that diagnosis is added to the transaction and then any of the following may occur, depending on how your administrator has configured the setting above: you may be warned that secondary diagnosis is appropriate, you may be prompted to select a secondary diagnosis, or the secondary diagnosis may be automatically added to the transaction. Keep in mind that you can always manually add or remove secondary diagnoses, regardless of how the setting above is configured. To do so, follow these steps:

1. In the DIAGNOSES section, select a diagnosis from the Existing, Favorites, or Department categories, or by Searching for it. The diagnosis is added to the Selected Codes area. If it is a primary diagnosis that should be accompanied by one or more secondary diagnoses, then one of the following workflows occurs, based on how the setting above is configured:
   • A Yellow Exclamation icon is displayed below the diagnosis code. You can do nothing, or you can click it to add a secondary diagnosis. When the Choose Secondary Dxs dialog is displayed, select one or more of the codes, and then click Ok to close it.
   • The Choose Secondary Dxs dialog box pops up automatically. Select one or more secondary diagnoses from the dialog, or select none, and then click Ok to close the dialog.
   • The secondary diagnoses are automatically added to the charge transaction without any user intervention. Please note that only the “preferred” secondary diagnosis codes are added (those listed above the “Additional Options” section of the dialog box). If necessary, you can delete any of the secondary diagnoses that are not appropriate for the patient by clicking Delete to the right of the diagnosis. You can also click the Yellow Exclamation icon to view and select from the diagnoses that are listed under the “Additional Options” section of the dialog box.
   If you selected a secondary code in any of the workflows above (or if they were selected automatically), they are now listed in the Selected Codes area of the Charge Transaction screen.
2. (Optional) If you want to view or re-display the Choose Secondary Dxs dialog box for any reason, you can click the Yellow Exclamation icon to display the dialog again, and then select a secondary diagnosis.

Show Settings that control this feature

• Admin - User - Problem List - Select Secondary Diagnoses

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Entering Diagnoses as Free Text

If you cannot find the diagnosis that you want by looking in the Favorites or Department categories, 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
• Adding a diagnosis on a clinical note
• Adding a diagnosis independent of a charge or note

The free text option is available only if your administrator has enabled it for you. Use free text diagnoses and sparingly, as all free text items must be reconciled by administrative staff.

1. In the DIAGNOSES section, click into the Search field and type a description of the diagnosis.
2. Review the search results to confirm that the item you are looking for does not already exist as a legitimate diagnosis code.
3. If you cannot find the item you want in the results, click on the Add as Free Text button, located at the top right of the search results list.
4. Your next step depends on your starting point:
   • If you are entering a charge transaction, the free text diagnosis is added to the Selected Codes section on the right side of the screen, followed by the Yellow Exclamation icon
   • If you are entering a clinical note, the free text diagnosis is added to the section of the note where you are currently working.
   • If you are adding a patient problem independent of a charge or note, the Add Problem screen is displayed, with the free text diagnosis shown on it.

Show Settings that control this feature

• When entering a diagnosis on a clinical note, or when adding a diagnosis independent of a charge or note: Admin - User - Problem List - Allow Free Text Diagnoses
• When entering a diagnosis on a charge transaction: Admin - User - Charge Capture - Allow Free Text Diagnoses

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Editing, Resolving, or Deleting Problems

To modify or delete a problem for a patient, follow these steps:

1. Select a patient on the Patient List tab, or click on the Details icon from another option.
2. Click the Problems display option. Any problems already associated with the patient are displayed in the summary Problem List window.
3. Click on the problem you want to modify or delete. The details of that problem are displayed in the Problem Detail window. At the top of the window are the Edit and Delete buttons.
   • To mark a problem as Resolved (the patient no longer has the condition because it has been resolved), you have two options:
   • Click the Resolve button associated with the problem on the Summary pane. Resolving a problem in this manner changes the Status from “Active” to “Resolved” and updates the Resolved and Last Used values with the current date and time.
   • Click the Edit button in the Problem Detail pane. In the Edit Problem window, select “Resolved” in the Status field. The Resolved values are updated with the current date and time.
   A Resolved problem continues to be displayed in the Problem List display option, but is removed from the Existing list when adding a charge transaction or clinical note.
   • To mark a problem as Inactive (the problem is not currently active for the patient):
   • Click the Edit button in the Problem Detail pane. In the Edit Problem window, select “Inactive” in the Status field.
   An Inactive problem continues to be displayed in the Problem List display option, but is removed from the Existing list when adding a charge transaction or clinical note.
   • To activate a problem that was previously marked as Resolved or Inactive:
   • Click the Activate button associated with the problem on the Summary pane. The Status changes to “Active,” the Resolved date and time are cleared (for previously Resolved problems), and the Last Used values are updated with the current date and time.
   • To delete a problem, click the Delete button, and then click Yes to confirm the deletion. You might delete a problem if it were entered in error. The problem is removed from the Problem List display option, as well as from the Existing list when adding a charge transaction or clinical note.
   • To modify the problem, click the Edit button. In the Edit Problem dialog box, change any of the desired fields, and then click Save.

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Managing Diagnosis Favorites and Department Categories

View a How-To Video on Managing your Favorites and Department Lists The Favorites category contains those diagnoses that you yourself have personally marked as favorites (or that your administrator has marked as favorites for you). The Department category contains the diagnoses that your administrator has deemed useful to all members of your department. You can make a substantial number of changes to the items within these two categories as indicated by the topics above.

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Adding or Removing Items to/from the Diagnosis Favorites Category

View a How-To Video on Managing your Favorites and Department Lists (including adding/removing favorites) You can mark or unmark any number of items (diagnosis codes, diagnosis macro groups, search terms, or subcategories) as personal favorites, so that they appear in the Favorites category in the DIAGNOSES section. There are several ways to do this, as indicated by the topics above.

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Creating a New Search Term for the Diagnosis Favorites Category

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Unfavoriting an Item That Is Listed in the Diagnosis Favorites Category

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Showing or Hiding Items in the Diagnosis Department Category

View a How-To Video on Managing your Favorites and Department Lists (including showing/hiding department items. Your administrator defines the diagnosis items that are included within the Department category for all users in the department. If an item or subcategory is not useful to you, you can hide it in order to make your diagnosis lists more streamlined. At any time, you can also show it again if you decide it is something you need after all. (Note that you cannot show/hide items in the Existing or Favorites categories.)

1. Depending on your starting point, use either of these methods:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading.
   • From the Problem Selection screen, click More , located on the far right side of the heading, and then select Diagnosis List Management from the menu.
2. Click on the Department category to open it and review the contents. If there are subcategory folders defined, click on them to expand them as well so that you can review their contents. A Show/Hide toggle button ( or ) is located to the right of every subcategory, as well as next to each item within that subcategory.
3. Identify an item or subcategory that you want to show or hide and then click the Show/Hide button next to that item to change its status.
   • When an item or subcategory is currently visible, the Show/Hide button looks like this:
   • When an item or subcategory is currently hidden, the Show/Hide button looks like this:
4. Click Close at the top right corner of the Diagnosis List Management screen.

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Sorting Items in the Diagnosis Existing, Favorites, or Department Categories

View a How-To Video on Sorting your Existing, Favorites, and Department Lists. On the various diagnosis lists, items are sorted as follows:

• Existing: Diagnosis codes are sorted in reverse chronological order by the date last used (most recently used codes first).
• Favorites: After you mark an item as a favorite, it is immediately added to the very top of the Favorites category.
• Department: The codes and subcategories have a specific, predefined sort order, as defined by your administrator.

At any time, you can change the order in which the codes are listed in these categories, to display them in a more meaningful manner.

1. You can sort items using either method below:
   • If you want to sort directly from the Charge Transaction, NoteWriter template, or Problem Selection screen, start at Step 2 below.
   • If you want to work from the Diagnosis List Management screen:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading, and then proceed to Step 2.
   • From the Problem Selection screen, click More , located on the far right side of the heading, select Diagnosis List Management from the menu, and then proceed to Step 2.
2. Click on the Existing, Favorites, or Department category to open it and review the contents. If there are subcategory folders defined, click on them to expand them as well so that you can review their contents. A Sort button is located to the right of the Existing, Favorites, and Department main categories, as well as next to the subcategories within those categories. Note that a category/subcategory must be open before the Sort button becomes available.
3. Identify a category whose codes or subcategories you want to reorder and then click Sortnext to that category.
4. Choose the manner in which you want to sort:
   • Sort Folder Content by Code: Sorts the diagnoses within the selected category alphanumerically by code. This does not impact the content of any subfolders within the category.
   • Sort Folder Content by Description: Sorts the diagnoses within the selected category alphabetically by description. This does not impact the content of any subfolders within the category.
   • Sort Folder Content by Last Used: This option appears only for the Existing category. It sorts the diagnoses by the date the code was last used for the patient (which is listed in parenthesis next to each diagnosis).
   • Sort Subfolders by Description: This option appears only if subfolders exist within the selected category. It sorts the subfolders alphabetically but does not impact the other content within the current folder.
   • Drag and Drop: If you are working from the Diagnosis List Management screen, you can use drag and drop to change how items are sorted. Just click and hold on an item, drag it to a new position, and drop it.
   • In the Favorites category:

• If you are sorting the individual diagnosis codes, macro groups, or search terms within a given folder, you can just drop an item to a new location within the folder contents.
• If you drop a diagnosis code, diagnosis macro group, diagnosis search term, or folder directly on top of a folder name, it goes into that folder.
• If you drop a folder just above or just below another folder name (at the top third or bottom third of the folder name), it goes above or below that folder, at the same level.
  • In the Department category:
• Only top-level Department folders can be dragged and dropped. Subfolders and individual items within a folder cannot be moved.
• If you drop a top-level folder just above or just below another top-level folder name (at the top third or bottom third of the folder name), it goes above or below that folder, at the same level.
• Department folders cannot be moved into another Department folder. For example, if you drop a folder directly on top of another folder, it does not move.
  • Department folders cannot be moved into the Favorites folder, or vice versa.
  • Click Close at the top right corner of the Diagnosis List Management screen.

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Creating a Subcategory for Diagnosis Favorites

View a How-To Video on Managing your Favorites and Department Lists (including creating a Favorites subcategory) If you designate a lot of diagnosis codes as favorites, your Favorites list may eventually become too long and disorganized to be useful. In this case, you can create subcategory folders to better organize your Favorites list. (Note that you cannot create new subcategories in the Existing or Department categories.)

1. Depending on your starting point, use either of these methods:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading.
   • From the Problem Selection screen, click More, located on the far right side of the heading, and then select Diagnosis List Management from the menu.
2. Click on the Favorites category to open it and review the contents. If there are already subcategory folders defined, click on them to expand them as well so that you can review their contents.
3. Add a new folder for a subcategory:
   • Click Add Folder just below the Favorites heading to add a child folder directly beneath it.
   • Click Add Folder just below an existing subcategory to add a child folder directly beneath it.
   A new folder is created with a default name of “New Folder.”
4. Click into the folder name field, replace the words “New Folder” with the desired subcategory name, and then click anywhere outside of the field. The newly named subcategory is created. You can now add items to it by dragging an item from elsewhere in the Favorites category and dropping it into the newly named folder (drop it directly onto the folder name).
5. Click Close at the top right corner of the Diagnosis List Management screen.

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Renaming Items or Subcategories in Diagnosis Favorites

View a How-To Video on Managing your Favorites and Department Lists (including renaming a Favorites subcategory) You can rename any item listed in the Favorites category, which includes the items below. When you rename one of these items, it is renamed only in your personal Favorites list; it is not changed system-wide.

• Subcategory names
• Diagnosis code descriptions
• Diagnosis macro group names
• Diagnosis search term names

To rename an item:

1. Depending on your starting point, use either of these methods:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading.
   • From the Problem Selection screen, click More , located on the far right side of the heading, and then select Diagnosis List Management from the menu.
2. Click on the Favorites category to open it and review the contents. If there are subcategory folders defined, click on them to expand them as well so that you can review their contents.
3. Identify the item or subcategory that you want to rename, and then click Edit to the right of its name. The name becomes an editable field.
4. Click into the name field, change or replace the existing name with the desired name, and then click anywhere outside of the field. The item is renamed.
5. Click Close at the top right corner of the Diagnosis List Management screen.

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Deleting a Subcategory from Diagnosis Favorites

You can delete a Favorites subcategory if it is no longer useful. When you delete a subcategory, that subcategory and all the items within it are removed from the Favorites list. If an item was listed in the deleted subcategory, as well as in another subcategory elsewhere within Favorites, it is not removed from the other subcategory.

1. Depending on your starting point, use either of these methods:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading.
   • From the Problem Selection screen, click More, located on the far right side of the heading, and then select Diagnosis List Management from the menu.
2. Click on the Favorites category to open it and review the contents. If there are subcategory folders defined, click on them to expand them as well so that you can review their contents.
3. Identify the subcategory that you want to delete, and then click Delete to the right of the subcategory name.
4. When asked to confirm the deletion, click Delete. The subcategory and all the items within it are removed from the Favorites category.
5. Click Close at the top right corner of the Diagnosis List Management screen.

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Pinning a Diagnosis Category or Subcategory Open

View a How-To Video on Managing your Favorites and Department Lists (including pinning a category open) You can “pin” a category or subcategory open, so that it is always displayed as “open” whenever you access the Charge Transaction, NoteWriter template, or Problem Selection screen. You can do this for the main Existing, Favorites, and Department categories, as well as for any of the subcategories underneath them.

1. Depending on your starting point, use either of these methods:
   • From the Charge Transaction screen, click Settings , located on the far right side of the DIAGNOSES section heading.
   • From the Problem Selection screen, click More, located on the far right side of the heading, and then select Diagnosis List Management from the menu.
   A Pin toggle button ( or ) is located to the right of the Existing, Favorites, and Department categories, as well as next to all of the subcategories underneath them.
2. Identify the main category (Existing, Favorites, or Department) or subcategory that you want to pin open or closed. Then click the Pin button next to that item.
   • When a category/subcategory is currently pinned open, the Pin button looks like this: . Note that when you pin open a subcategory (such as a subcategory under Favorites), it automatically also pins open the parent category (the Favorites category in this example).
   • When a category/subcategory is currently pinned closed, the Pin button looks like this: . Note that when you pin closed a main category (such as Favorites), all subcategories underneath it are automatically pinned closed as well.
3. Click Close at the top right corner of the Diagnosis List Management screen.

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Showing or Hiding Numeric Diagnosis Codes

You can opt to either show or hide the numeric ICD-10 codes for all the diagnoses that are listed in the Problem Selection screen. When you choose to show the codes, the screen shows both ICD-10 codes and diagnosis descriptions. When you choose to hide the codes, the screen shows only diagnosis descriptions. This preference affects all codes in the Existing, Favorites, and Department categories, and it also shows or hides the codes in the search results when you perform a search for a diagnosis. The setting for this preference is available on the Problem Selection screen that is seen when adding a problem via the Patient List > Problems display option, but please note that whatever choice you make there (to show or hide the codes) also affects the Problem Selection screen that is seen when entering a diagnosis on a clinical note. To set your preference for showing or hiding diagnosis codes when entering problems or clinical notes:

1. From the Patient List > Problems display option, click Add to add a new problem.
2. Click Find Problem. The Problem Selection screen opens.
3. Click More at the far right side of the Problem Selection heading.
4. Check or uncheck (the default) the box for the Hide diagnosis codes option, as desired.

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Showing or Hiding Inactive Diagnoses on the Existing List

You can opt to either show or hide any discontinued diagnoses on the patient’s Existing list. Diagnosis codes are updated each year, and as a result, a code that was included on your patient’s Existing list in the past (such as an old ICD-9 code) may be inactive today. Please note that this is different from a patient diagnosis that has been marked as resolved or inactive because the patient no longer has the condition. Patient diagnoses that were marked as resolved or inactive never show on the Existing list. The setting for this preference is available on the DIAGNOSES screen that is seen when adding a diagnosis on a clinical note, and it affects only that screen. To set your preference for showing or hiding inactive diagnoses on the Existing list when entering clinical notes:

1. Start the process for entering a clinical note, and then click into the DIAGNOSES field on any section of the note that contains that field (such as the A/P section). The DIAGNOSES field expands to show the Existing, Favorites, and Department lists.
2. Click More at the far right side of the heading.
3. Check or uncheck (the default) the box for the Hide inactive diagnoses option, as desired.