Select an Assessment from Clinical Problems

On the Add or Update Assessment template, Clinical Problems section, filter the grid by selecting Show chronic, Show my tracked problems, or No active problems.
Select a Clinical Problem item from the grid.
A system check determines if there was a previously mapped ICD code for that clinical problem for the open patient chart. If there is a previously saved mapping, that ICD code is added to the ICD description and ICD Code fields to be used for today’s assessment.

The Clinical Problems section includes the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED - CT®) problem list (from the Concept Id column on the Problem List tab in the Problems module). The system translates the selected diagnosis into a SNOMED® code and saves it in the Clinical Problems section.

Note: The SNOMED list contains healthcare concepts with unique meanings and formal, logic-based definitions organized into hierarchies. The list provides the ability to consistently index, store, and retrieve clinical data across specialties and sites of care. Notice the Onset Date column in the grid for Clinical Problems. A date of onset is required by the Centers for Medicare and Medicaid (CMS) for any problem that appears in the chronic list. The Clinical Problems include both chronic and acute problems.
If no previously saved mapping is available, the system determines the following:
- If one-to-one mapping exists, the ICD description and ICD Code fields above the grid automatically populate for Today's Assessment.
- If one-to-many mapping exits, a list of mapped problems appears to select the appropriate value.
- If no mapped value exists, a message appears stating that no mappings exist for the selected assessment.
Continue documenting the assessment on the Assessments tab.