Diagnosis Section - PM

Enter the diagnosis information in the Working Diagnosis form.

1. In the Type Of Diagnosis field, select the diagnosis type. Selecting Admission or Discharge populates the Date of Diagnosis field with the client's admission or discharge date.
2. In the Date Of Diagnosis field, enter the diagnosis date.
3. In the Time Of Diagnosis field, enter the diagnosis time.
4. In the Diagnosis fields for Axis I through Axis III, select the diagnoses.
   Note: Diagnoses fields are enabled if Accepted is selected as the Type of Diagnosis for the corresponding Diagnosis field in the Working Diagnosis section.
5. The Remarks fields are automatically populated with the diagnosis remarks entered in the previous section.
   Note: The Remarks fields display if the Add Axis I, II and II Remarks registry setting is enabled.
6. In the Present On Admission Indicator fields for Axis I through Axis III, select how the diagnosis was indicated at admission.
7. In the Principal Diagnosis field, select the diagnosis. The selections for this field include the diagnoses entered in the Axis I, Axis II, and Axis III Diagnosis fields in this section.
8. In the DRG Code field, select the code.
   The selection in the Principal Diagnosis field defaults the associated DRG Code. If the Principal Diagnosis does not have an associated DRG, the system will review each Axis I entry, then each Axis II entry, then each Axis III entry for an associated DRG. The first DRG found will default.  DRG Codes can be defined and associated with ICD-9 Codes in the RADplus Utilities - Diagnosis Table Maintenance form.
9. For the following Axis IV fields, select Yes or No as applicable:

• Primary Support Group
• Social Environment
• Educational
• Occupational
• Housing
• Economic
• Health Care Services
• Legal System/Crime
• Other Problems

10. If Yes is selected for an Axis IV item, enter remarks as appropriate.
11. In the Diagnosis - Axis V Current GAF Rating field, select the client’s current GAF (Global Assessment Functioning).
12. In the GAF- Highest Level Last 12 Months field, select the client’s highest GAF.
13. In the GAF- Lowest Level Last 12 Months field, select the client’s lowest GAF.
14. For the Diagnosing Practitioner field, enter the practitioner name or ID, and select.
15. In the Estimated Discharge Date field, enter the discharge date.
16. In the Prognosis field, enter the appropriate prognosis information.
17. In the Secondary Diagnosis and Tertiary Diagnosis fields, enter the diagnosis.
    Note: The Secondary and Tertiary Diagnosis fields display if the Add Secondary and Tertiary Diagnosis registry setting is enabled.
18. Select Submit.