Diagnoses

This page will explain the purpose of Diagnoses codes and how to use them.

Diagnoses

TRAKnet currently supports ICD-9 coding for diagnoses and is ICD-10 ready come October 1, 2015. Diagnoses, otherwise known as problems, are the method by which all current and past diagnoses for a patient will be recorded. These are recorded on both a patient level and a visit level.

Documenting in Patient's Chart

To document a diagnoses from the patient's chart, search for the desired patient to open their electronic chart. From the top of the screen, click Problems/Diagnoses. This will open the Problems window.

The top of the window will be titled the patient's name, date of birth and gender.

The screen will otherwise be broken down into three sections: All Active Problems, Inactive/Resolved Problems, and Add New Problems. A breakdown of each section follows.

All Active Problems

The All Active Problems portion of this screen will list all current and active diagnoses that have been previously added to the patient's chart. This will be listed with the following information:

  • Date - The date the diagnosis was recorded.
  • Code - The ICD-9, eventually ICD-10, code for that diagnosis, e.g. 250.00.
  • Description - The description of that diagnosis, e.g. Diabetes mellitus without mention of complication…
  • Onset Date - Optional. The date this problem began for the patient.
  • Inactive - A button to mark this diagnosis as Inactive.
  • Resolved - A button to mark this diagnosis as Resolved.

Problems are added to this list using the Add New Problems feature. Problems can be marked as inactive or resolved but cannot be deleted from the chart.

Inactive/Resolved Problems

The Inactive/Resolved Problems portion of this screen lists all previous diagnoses that have been marked as resolved or inactive. They will be listed with the following information:

  • Date - The date originally added to the patient's chart.
  • Code - The ICD-9, eventually ICD-10, code for that diagnosis, e.g. 250.00.
  • Description - The description of that diagnosis, e.g. Diabetes mellitus without mention of complication…
  • Status - That current status of that diagnosis, e.g. Inactive, Resolved.
  • Make Active - A button to mark this diagnosis as Active once again.

Add New Problems:

The Add New Problems portion of the screen is where new problems or diagnoses will be documented. There are three tabs and methods of navigation in this portion:

  • SmartSheet10 - This tab will utilize TRAKnet's built in SmartSheet10 Technology to display a list of favorite diagnoses with their I9 and I10 codes present. They can be added to the chart with the "Select" button. SmartSheets can be created under the SmartSheet10 module at the top of the main screen of TRAKnet.
  • ICD-9 Favorites - This tab presents a quick list of diagnoses codes that have been flagged as favorites under the ICD-9 Search tab. Favorites lists can be created per user or per practice. To add a code to the patient's chart, click the "Add" button. To remove a favorite from the list, check the Edit Favorites checkbox at the top of this tab, then click "Delete."
  • ICD-9 to ICD-10 GEMs - This tab contains a search box where ICD-9 codes can be looked up and associated with an ICD-10 code. You may search by either code, e.g. 487.8, or description, e.g. "bunion." Once your desired dual code has been found, click "Add" to add to the patient's chart. If you would like to add this code to your Smartsheet list, click "Favorite" to open the Favorite Codes pop-up box. From this box, rename the list of Smartsheets if you'd like, then click Add to My Favorites to generate a personal list of Smartsheets or Add to Practice Favorites to generate a list of practice-wide Smartsheets.

Finalizing

Once you have completed updating diagnoses on the patient's chart, click "Save" to save your changes. If you do not want to save your changes, click "Cancel."

(ARCHIVED) As a Measure in Meaningful Use Stage 1

While this is no longer a requirement in Meaningful Use in 2015, the below video is left archived as a demonstration for documenting patient diagnoses.

For the most up to date video on Meaningful Use, please click here.

Related Pages

Charting an Encounter
Creating a Claim

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