Add or Edit a Diagnosis Template
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Last Modified on 09/27/2022 10:52 am EDT
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Version 14.19
Path: Clinical tab > Encounter Templates
About
Below, you'll learn how to manage your Diagnosis Template to ensure that they reflect the workflow of your Practice:
Add or Edit a Diagnosis Template
- Navigate to Encounter Templates by following the path above.
- Click the + to the left of the System Name to expand the System group or click into the Search field and type a template name, and press Enter.
- Follow the step below to add or edit a template.
- Add a template: Click the Add button.
- Edit a template: Select a template, and click the Edit button or double-click to open the template. Once the template is displayed, click the Edit button.
- Review, edit or add template properties using the definitions found in the table below.
| Property | Description |
|---|
| Template | The name given to a template should be easily identifiable and easy to search. of searching. Diagnosis Template titles are written in all capital letters. |
| Category | Method of organizing similar Templates. |
| 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. This is not a requirement to save the Template. |
| Visibility | Ability to restrict who can view the selected Template. All Diagnosis Templates should have a visibility level of at least Provider. |
| Location | Assignment can be made to view Templates by Location. Leave this blank if the Template should be available at all Locations. |
| Finalize Status | This is who can finalize Notes where the template is applied. Most Templates will be set to Providers only. |
| Default place of service (Optional) | Used with Templates that are non-office, such as Telehealth, to automatically populate the Place of Service on the Visit Information tab of an Encounter Note. |
- Click the Encounter Note tab if not already selected.
- Review, edit or add the information, in fields of the Encounter Note tab, using the definitions found in the table below.
| 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 the time of the visit. |
| Assessment (Optional) | The likely diagnosis or additional diagnoses that need to be ruled out can be included in this section of the note. |
| 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 as well as timings for further review or follow-up are generally included. |
| Instructions | Instructions entered will be visible on the Patient Exit Note. Instructions are typically a summary of the visit written for understanding by the reader. |
- Add a Diagnosis Code.
- Click the Add button.
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| Note: Select the Prim? checkbox when 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 and click the Search button. The ICD10 search window displays.
- Enter a description or code in the ICD10 Code/Description field and select the Diagnosis Code.
- (Optional) Click the drop-down in the Problem Status field and select from the list.
|
| Note: If a Problem Status is not selected in the Encounter Template Editor, it may be selected when charting an Encounter visit. |
- Click into the SNOMED Description field, begin typing and click the Search button. Select the SNOMED code.
- Click the Save button.
- Click the Detailed Exam tab and review, edit or add the exam points using the table definitions below.
| Setting | Description |
|---|
| Pert | Relevant symptom/question to display when the Template is opened. |
| ABNL | Positive for the finding |
| NL | Negative for the finding |
| N/A | Not applicable for the Template; removes from the group list. |
|
| Note: To expand an exam group, click the heading. Select the Show all groups checkbox to see additional Exam groups.
|
- Click the Orders/Workflow tab. Select from the below list for detailed instructions on adding to the Orders/Workflow tab.
- (Optional) Click the Procedures tab. Click here for detailed information on completing the Procedures tab.
- Click the Save button.
Validate DX Codes
It’s recommended to validate your Encounter Template DX Codes annually (close to but after October 1st) to ensure that the DX Codes you have on your templates are valid and specific.
- Navigate to Encounter Template Editor: Clinical tab > Encounter Templates.
- Click the Validate DX button.
- Review the confirm pop-up and click OK when you’re ready to continue with running the validation. A validation progress bar is displayed on-screen giving you the opportunity to acknowledge each insufficient code found in your templates.
- When validation is complete, revisit the identified templates and update the DX Codes to be appropriately coded for specificity.
Version 14.10
Utilities > Manage Clinical Features > Encounter Template Editor
Overview
This article will help to provide you with an understanding of the content for a typical diagnosis template. You will be instructed on methods of customization to ensure the diagnosis templates reflect the workflow of the practice.
- Click Utilities in the main menu.
- Select Manage Clinical Features.
- Select Encounter Template Editor. The template list displays.
- Click the plus to expand System group.
- Double-click to open a template and click the Edit button
. - Review the template properties.
| Property | Description |
|---|
| Template | Name given to a template. Should be named for ease of searching. Diagnosis template titles are written in all capital letters. |
| Category | Method of organizing like templates. |
| 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 Diagnosis templates should have a visibility of at least Provider. |
| 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. |
- Click the Encounter Note tab if not already selected.
- Review and edit 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 as well as 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. |
- (Optional) Add a diagnosis code.
- Click the Add button
.
| Note: Click the Prim? checkbox when 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 and click the Search button. The ICD10 search window displays.
- Enter a description or code in the ICD10 Code/Description field and select the diagnosis code.
- Click into the SNOMED Description field, begin typing and click the Search button. Select the SNOMED code.
- Click the Save button.
- Click the Detailed Exam tab and review or change the exam points using the table definitions below.
| Setting | Description |
|---|
| Pert | Relevant symptom/question to display when template is opened. |
| ABNL | Positive for the finding |
| NL | Negative for the finding |
| N/A | Not applicable for the template. Removes from the group list. |
 | Note: To expand an exam group, click the heading. Select the checkbox Show all groups to see additional Exam groups. |
- Click the Orders/Workflow Tab. Click here for detailed information on each tab in Orders/Workflow.
- Click the Procedures tab. Click here for detailed information on completing the Procedures tab.
- Click the Save Changes to template button
.
