Diagnoses window

Patient Diagnoses Group Dates

If you use diagnoses groups, select the time period to filter diagnoses that are active during this period. Select  to view all the diagnoses for the selected patient. For more information, see Patient Diagnoses Group Dates Dialog. Diagnoses groups are available only in Host Mode.

Create/Edit Patient Diagnoses Group Dates

You can manage patient diagnoses group dates in the Patient Diagnoses Group Dates Dialog. Diagnoses groups are available only in host mode.

View All Patient Diagnoses Groups

You can view the diagnoses information across the periods in the View Across Periods Dialog. Diagnoses groups are available only in host mode.

Description

You can select diagnosis or procedure description for the corresponding code in ICD-9/ICD-10.

If the code is not valid, the description includes *** and the message appears notifying you that you need to specify a valid code.

ICD-9/ICD-10

In host mode, select the ICD-9 or ICD-10 code. To search for a diagnosis or procedure, click . For details, see Select Diagnosis/Procedure Dialog.

In field mode, this column is read-only.

Note: The access to these sections depends on your privileges.

Free Text

In host mode, this section appears if you have the appropriate privilege.

Using the Free Text section, you can manage free-text diagnoses, procedures, and inpatient diagnoses:

• If you are adding new records, see Adding Free-Text Diagnoses for a Patient and Entering Free-Text Procedures for a Patient. For details on how to add free-text inpatient diagnoses, see Adding Free-Text Inpatient Diagnoses for a Patient (Field Mode).
• If you are converting free-text records, click  to search for the code that corresponds to the specified description. See Converting Free-Text Diagnoses and Procedures (Host Mode).
• Note: Free-text inpatient diagnoses should be also converted in the assessments. See Inpatient Diagnoses workflows.

Type

This field is available in the Free Text section only. Select one of the following values:

• Free Text – Select if you entered a free-text description of the diagnosis or procedure (used for manual conversion of free text into the ICD codes). 
• Note: If you enter free text in host mode, then the Type field is prefilled with the free text value and cannot be edited.
• ICD-9 or ICD-10 – Select the corresponding ICD code type for the code entered in the Description field (used for automatic conversion of free text into the ICD codes).

Special

Specify the appropriate special diagnosis indicator:

• Onset – Indicates that the date defined is the date when the patient was diagnosed.
• Exacerbation – Indicates a worsening of the diagnosis.
• OASIS/Reference – Diagnosis codes are not included in orders, claims, or assessments.

Start Date / End Date

Specify the dates as needed:

• Start Date – Date when the diagnosis or procedure becomes effective for a patient.
• End Date – Date when the diagnosis or procedure no longer applies to a patient.

Do Not Create Order / Do Not Create End Order

These columns depend on the For Start Diagnosis and For End Diagnosis settings in Administration > Configuration > Business Units > Basic > Settings > Orders Settings.

Select the following options to suppress generation of orders for the start or end diagnosis:

• Do Not Create Order – Do not generate supplemental orders for the start diagnosis (if the start date is entered for this diagnosis).
• Do Not Create End Order – Do not generate supplemental orders for the end diagnosis (if the end date is entered for this diagnosis).

Sequence

With the sequence column, specify the ranking of the diagnoses within a group.

Diagnosis with a 1 sequence is a primary diagnosis. After changing a primary diagnosis in a group, the patient status record is updated automatically with the new primary diagnosis. After changing the start date of the group, the primary diagnosis may also change and will be updated in the patient status record in Patient > General > Admissions & Status.

Note: This column is available only if the group date is selected in the Patient Diagnoses Group Dates drop-down list. If you view all diagnoses, the Sequence column is not displayed. Diagnoses groups are available only in host mode.

Terminal Illness

The Terminal Illness column is available only for hospice patients. In this column, you can specify patients' terminal diagnoses that are printed on the on the CMS-1500 (08/05), CMS-1500 (02/12), and UB-04 forms.

If you use diagnoses groups, specify a patient's terminal diagnoses within each separate group because the Terminal Illness column is not available for the  view.

If a patient has several groups with the terminal illness diagnosis, consider the following cases:

• If you delete all groups at the same time and save your changes, the terminal illness diagnosis that was selected in at least one group remains selected in the Diagnoses window.
• If you delete one group, save your changes, and then delete another group, the terminal illness diagnosis from the last group remains selected in the Diagnoses window.

M1024

The M1024 column is available for the diagnoses group with the patient class where OASIS is used when entered in the ICD-9 column. The diagnosis sequence range is 1–6.

The 3 and 4 columns for the M1024 diagnosis are active only for the V-code diagnoses. The 3 column is active for PPS Case Mix diagnosis entry. The 4 column becomes active for PPS Case Mix diagnosis entry after the 3 column is completed.

Note: The V and E codes are not allowed for the M1024 diagnoses. The M1024 diagnosis entry is not required.

M1025

The M1025 (3) column is available if a diagnosis with the Z code is entered for the corresponding ICD-10 diagnosis and the underlying diagnosis is resolved.

After you select a diagnosis in the M1025 (3) column, the M1025 (4) column becomes active for diagnosis entry. You may complete the M1025 (4) column only if the optional diagnosis is a multiple coding situation (for example, a manifestation code).

Note: The V, W, X, Y, or Z codes are not allowed for the M1025 diagnoses. The M1025 diagnosis entry is not required.