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Using PCE

How to Add or Edit Diagnoses (ICD 9)

You can enter a diagnosis and/or an ICD-9 code for a patient’s encounter. You will be prompted to designate the diagnosis as primary or secondary.  CIDC (Clinical Indicator Data Capture) has added functionality that displays patient Service Connected and Rated Disabilities for those SC patients. In addition, an optional Ordering/Resulting Diagnosis prompt asks “Is this Diagnosis Ordering, Resulting, or Both.” See NOTE in Step 3.  

With functionality put in place by the Code Set Versioning project, only ICD Codes that are active for the encounter date and time will be available.

Steps to add a Diagnosis

1. Select UE from the PCE Appointment List screen.

2. Select DX from the PCE Update Encounter screen.

The sample below is from PCE Data Entry, also note that these prompts are seen in the Appointment Manangement Check-Out option.

PCE Update Encounter          Aug 21, 2003@15:57:33          Page:    1 of    1

PCEpatient,one    000-00-0001P              Clinic:  GENERAL MEDICINE AT ALBANY

Encounter Date  6/25/2003  10:00        Clinic Stop:  301  GENERAL INTERNAL MEDI

  1 Encounter Date and Time:  JUN 25, 2003@10:00

          + Next Screen   - Prev Screen   ?? More Actions

ED  Edit an Item          TR  Treatment             DD  Display Detail

DE  Delete an Item        IM  Immunization          DB  Display Brief

EN  Encounter             PE  Patient Ed            IN  Check Out Interview

PR  Provider              ST  Skin Test             QU  Quit

DX  Diagnosis (ICD)       XA  Exam

CP  CPT (Procedure)       HF  Health Factors

Select Action: Quit// DX   Diagnosis (ICD 9) [ENTER]

Patient's Service Connection and Rated Disabilities:

       SC Percent: 100%

Rated Disabilities: TRAUMATIC ARTHRITIS  (10%-SC)

                   DIABETES MELLITUS  (0%-SC)

--- Diagnosis ---

 1   891.0     OPEN WND KNEE/LEG/ANKLE

 2   200.01     RETICULOSARCOMA HEAD

Enter 1-2 to Edit, or 'A' to Add: A [ENTER]

30PCE V. 1.0 User ManualAugust 1996

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