In the Assessment/Diagnosis panel, confirm the assessment selected displays in the Description details and ICD Code field. If not, select the assessment in the grid to fill in the details.
Add Status, Severity, Differential Dx, and Impression.
To enter specifiers in the Specifiers field, do one of the following:
Select in the field and enter free text.
Select the My Phrases link and select a phrase from the list.
If applicable, select Present on Admission and then select a description from the list.
To indicate the diagnosis is chronic, add the diagnosis to the client’s clinical problems list, and/or add the assessment to my tracked problems, select the respective checkbox.
Select Add To Grid.
The information displays in the grid.
To add psychosocial stressors, select the Psychosocial Stressors link.
To add referrals, select the Referrals link.
To reorder the diagnoses, select Sort.
To update a diagnosis, select the diagnosis in the grid, modify the details, and select Update.
