Edit a Diagnosis Template

Version 14.8
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. 

  1. Click Utilities in the main menu. 
  2. Select Manage Clinical Features.
  3. Select Encounter Template Editor. The template list displays.
  4. Click the plus to expand System group.

  1. Double-click to open a template and click the Edit button.
  2. Review the template properties.

PropertyDescription
TemplateName given to a template.  Should be named for ease of searching. Diagnosis template titles are written in all capital letters.
CategoryMethod of organizing like templates.
AuthorAssignment of a template to a specific user.  Templates assigned an author may only be edited by that user.
Appt TypeSelection of a default appointment type.  Not a requirement to save the template.
VisibilityAbility to restrict who can view the selected template.  All Diagnosis templates should have a visibility of at least Provider.
LocationAssignment can be made to view templates by location.
Finalize StatusSelection set to who may finalize.  Most templates will be set to Providers only.

  1. Click the Encounter Note tab if not already selected.
  2. Review and edit the fields of the Encounter Note tab.
FieldDescription
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.
PlanThis 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.
InstructionsInstructions 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. (Optional) Add a diagnosis code.
  1. 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.
  1. Click into the ICD10 Description field and click the Search button. The ICD10 search window displays.
  2. Enter a description or code in the ICD10 Code/Description field and select the diagnosis code.
  3. Click into the SNOMED Description field, begin typing and click the Search button. Select the SNOMED code.
  4. Click the Save button.
  1. Click the Detailed Exam tab and review or change the exam points using the table definitions below.
SettingDescription
PertRelevant symptom/question to display when template is opened.
ABNLPositive for the finding
NLNegative for the finding
N/ANot 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.
  1. Click the Orders/Workflow Tab. Click here for detailed information on each tab in Orders/Workflow.
  2. Click the Procedures tab. Click here for detailed information on completing the Procedures tab.
  3. Click the Save Changes to template button .