How to add a diagnosis to a client's health record/chart?
How to add a diagnosis to a client's health record:
When you have a client’s health record/chart open it shows 4 tabs across the top: Personal Information, Involved Clinicians, Diagnoses and Client’s Chart.
Click on the third tab: Diagnosis
The client may already have some diagnoses recorded from previous visits or other clinicians. At the bottom is a button to Add Diagnosis. Click on it.
A Diagnosis #new form will pop-up.
Fill in the Client, Doctor/Clinician and the Diagnosis in ICD-10 format or as Plain text. Hit Ok to save or Close if you are not saving the diagnosis.