Add a Diagnosis to Problem List from an Encounter or Well Visit Note

OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Version 21.0


When documenting an Encounter or Well note for a child, you may discover that a patient needs to have their Problem List updated with a diagnosis from the current note.

Add Diagnosis to the Problem List from a Visit

In this example, the user has documented mild persistent asthma in a patient's chart.  For accurate medical records, as well as optimal recalls and reports, this should be added to the patient's Problem List.

  1. From an open Visit Note, click Diagnoses.
  2. Add the diagnosis code (ex. J45.30) to the Diagnosis list. Fields such as Problem Status and SNOMED Description are optional.

Note: If the patient does not have Medication Allergies, click the No Med Allergies button, and click OK to confirm. This sets the indicator that the patient does not have active Medication Allergies.

  1. Select the Add PL checkbox on the right side.

  1. Next, you'll see a confirmation pop-up, asking you if you want to add the diagnosis to the patient's problem list:

  • To quickly add just the diagnosis to the Problem List, click Yes. The Problem List will automatically update with the diagnosis code and its description:

  • Alternatively, to add/edit other pertinent information, like Onset date, Note, etc., click Yes + Details. The Problem List window will open, where you can add the desired details, then click Save.