How to Add Diagnoses in the Physical Exam
There are two common ways to document a physical exam:
Users can document by each finding, beginning with selecting an abnormal finding and working horizontally across the columns that populate with each selection.
Users can also document across categories by scrolling vertically and selecting abnormal findings down each column.
1. In the Exam > Scroll to Physical Exam > Click findings
2. Click the X next to any item in the left-most column of the exam menu.
3. Select any diagnoses from the next column > Enter findings as neccessary, and choose whether you want to add a billable code (Diagnosis), or as a Finding Only
4. Scroll each column to locate any additional findings and diagnoses as needed > document any findings > Click Save when done
5. The abnormal findings are now added to the exam
6. The Diagnoses are also added to the Assessment/Plan, mapped with treatments as set up in the Configure section of the EHR
If there is a yellow banner to the left of an assessment, it means there is not an a SNOMED code associated with the ICD-10 code.
