Add a Diagnosis Template

Version 14.8
Utilities > Manage Clinical Features > Encounter Template Editor

Overview

You will have an understanding of the content of a typical symptoms template. You will be instructed on methods of customization to ensure the symptom templates reflect the workflow of the practice.

  1. Click the Utilities button  on the menu toolbar.

Menu Toolbar: Utilities

  1. Select Manage Clinical Features.
  2. Select Encounter Template Editor. The template list will display.
  3. Click the plus to expand a System group.


Encounter Template Editor: Diagnosis Template Group Expanded


It is not required to expand the group, but it is good practice to make sure you do not duplicate a template.
  1. Click the Create a new template button.
  2. Add the template properties using the table definitions below.

Encounter Template Editor: Template Properties

Property
Description
Template
Name given to a template. Should be named for ease of searching.
Category
Method of organizing like templates. All templates edited in this section will be located in the Symptom category.
Author
Assignment of a template to a specific user. Templates assigned an author may only be edited by that user.
Appt Type
Selection of a default appointment type. Not a requirement to save the template.
Visibility
Ability to restrict who can view the selected template. All symptom templates will have a visibility of Any Staff Member.
Location
Assignment can be made to view templates by location.
Finalize Status
Selection set to who may finalize. Most templates will be set to Providers only.
  1. Click the Encounter Note tab  if not already selected.
  2. Complete the fields of the Encounter Note tab.
Field
Description
Counseling (optional)
Information entered includes counseling that is commonly done during the visit.
Coordination of care (optional)
Information entered includes activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Typically the information in this field is entered at time of visit.
Assessment (optional)
The likely diagnosis should be included in this section of the note. If a conclusive diagnosis has not been made yet, some possible diagnoses can be charted. It may include additional diagnoses that need to be ruled out.
Plan
This describes what will be done to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc. This should address what was discussed or advised with the patient and timings for further review or follow-up are generally included.
Instructions
Instructions entered will be visible on the Patient Portal when the template is selected. Instructions are typically a summary of the visit written for understanding by the reader.
  1. Add a diagnosis code.
  • Click the Add button.
  • Click the Prim? checkbox if the code is the primary diagnosis.
    • If the diagnosis code involves laterality, severity, etc., you can add multiple Primary Diagnosis codes that will create a pop-up when the template is applied to select the most specific code for that visit .
  • Click into the ICD10 Description field.

  • Click the Search button. The ICD10 Search window displays.
  • Enter a description or code in the ICD10 Code/Description field.
  • Select the diagnosis code.
  • Click the SNOMED link button.

  • Select the SNOMED code.
  • Click the Save Entry button.
  1. Click the Detailed Exam tab .
  2. Set the exam points.
Setting
Description
Pert
Relevant question to display when template is selected.
Reports
Positive for the exam point
Denies
Denies the exam point
N/A
Not applicable for the template. Removes from the group list.


Note:  To expand an exam group, click the heading or the plus button.
  1. Click the Orders/Workflow tab.
  2. Click the Procedures tab.