Add free-text diagnoses for a patient

Path: General > Diagnoses > Medical Diagnoses

Prerequisite: To manage free-text diagnoses in host mode, you need to have the corresponding privilege granted by the administrator.

1. In the Patient component, select a patient.
2. Go to General > Diagnoses > Medical Diagnoses.
3. In the Free Text section, add a row.
   1. Note: The first empty row is added by default.
4. Do one of the following according to your agency process:
   1. Manual Conversion:
      1. In the Description field, type a diagnosis name and any important details (if you use diagnoses groups, you can include the sequence to help a coder with conversion).
      2. In the Type drop-down list, select Free Text.
         1. In host mode, this value is autocompleted.
   2. Automatic Conversion (for Field Mode only):
      1. In the Description field, enter a valid code.
      2. In the Type drop-down list, select the type of the specified code: ICD-9 or ICD-10.
5. Enter the start date.
6. If needed, select Special indicator.
7. If the diagnosis is primary, select the corresponding check box. For new patients, select this diagnosis in the Admissions & Status window (it is shown as To be coded).
8. For hospice patients, if the diagnosis is a terminal illness, select the Terminal Illness check box.
9. Save your changes.