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