You are able to enter in a new diagnosis for a client or update an existing diagnosis by following the steps below.
Jump to Section: [Add a Diagnosis] [Edit an Existing Diagnosis] [Enter a Diagnosis from New or Pending Client Notes]
Add a Diagnosis
- Click My Clients from the navigation bar and open the appropriate Client, or search for the Client in the Client Search field.
- Click the Clinical Information tab.
- Click on the Blue Clipboard icon to add a new diagnosis. This will bring you to the Add Diagnosis pop-up window.
- Fill in the ICD or DSM code or description, and any other diagnostic information that is need. Then click Confirm Diagnosis.
Edit an Existing Diagnosis
- To edit an existing diagnosis, click on the Blue Clipboard icon in the Clinical Information tab.
- From the Add Diagnosis pop-up window, click the Pencil icon to the right of the diagnosis.
- Make any needed edits, then click Confirm Diagnosis.
Enter a Diagnosis from New or Pending Client Notes
From a New Note
- If you are creating a new note for a client, the existing diagnosis from their Client File should automatically populate in the note.
From a Pending Note
- If you have made a change to their diagnosis on the client's file and you have pending notes for this client, you will need to update the diagnosis on those pending notes to match the update made on the client's file.
- From the Client File, click Notes.
- Click the Paper and Pencil icon to edit a pending note.
- Scroll down to the Diagnosis section, then click on the Pencil icon to edit the existing diagnosis.
- You can click the Pencil icon to edit the existing diagnosis, or click the X to delete the existing diagnosis. You can also enter in a new ICD or DSM code or description to add a new diagnosis, then click Confirm Diagnosis.
- Save the note by either scrolling to the bottom of the page and clicking Save Note, or scrolling to the top and clicking Save.