Concept explainer
Diagnoses and problems
Explains how diagnoses and ongoing problems are recorded, coded and carried forward so clinicians see a current clinical picture.
Diagnoses and ongoing problems are recorded against a visit, coded with ICD-11, and carried forward so a clinician opens a current clinical picture. This page explains how a diagnosis is recorded, how it is coded, and how an ongoing problem follows the patient from one visit to the next.
Recording a diagnosis
A diagnosis is a coded condition recorded for a patient within one visit. A visit may carry several diagnoses. The record holds a diagnosis once its detail is complete, so a bare code on its own stays a draft until the clinician confirms it.
Each diagnosis names the clinician who recorded it and the time they did so. Atlas keeps the diagnosis against the visit, so the reason for a contact reads back clearly later.
The primary diagnosis
Each visit that carries a diagnosis has exactly one primary diagnosis, the condition that leads the visit. The rest sit as secondary conditions, comorbidities or complications. Promoting another diagnosis to primary moves the previous primary to secondary in the same step, so a visit always reads with one lead condition.
One primary at a time
The platform holds a visit to exactly one primary diagnosis. A change that would leave a visit with zero or two primaries is refused, so the leading condition of a visit stays unambiguous.
Diagnosis attributes
A diagnosis carries a set of attributes that describe it. Each is chosen from a fixed set of values.
| Attribute | What it records | Values |
|---|---|---|
| Type | The place the diagnosis holds in the visit | Primary, secondary, comorbidity, complication |
| Status | Where the condition stands | Active, resolved, active-chronic, ruled-out, unknown |
| Certainty | How settled the diagnosis is | Confirmed, provisional, differential |
| Severity | How severe the condition is | Mild, moderate, severe, critical, terminal |
| Prognosis | The expected course | Excellent, good, fair, poor, grave |
| Treatment response | How the patient responds to treatment | Initiated, responding, no response, side effects, contraindicated, completed, discontinued, on hold, successful |
Coding with ICD-11
Every diagnosis is coded with ICD-11, the coding standard the record treats as authoritative. A diagnosis carries one or more ICD-11 codes. Where another system speaks an older coding, the code is translated for that exchange while the record keeps the ICD-11 code as the source.
Ongoing problems carried forward
An ongoing problem is a diagnosis whose status is active or active-chronic. It carries forward across visits, so a clinician opening a later visit sees the conditions that are still live. A chronic condition or an allergy sits in the record as an active-chronic diagnosis, and follows the patient wherever they are seen.
A later visit can point to an earlier active or chronic diagnosis rather than re-entering it. The pointer is a read-only reference to the original, so the earlier diagnosis stays the single source and the later visit draws on it.
The change trail
Every change to a diagnosis is kept as an entry in an append-only history, keyed to that diagnosis. The history records the attribute that changed, its value before and after, the clinician who changed it, and the time. This is the source of the change history a clinician reads beside the diagnosis.
Common confusions
Can a visit carry more than one diagnosis?
Yes. A visit may carry several diagnoses, and exactly one of them is the primary diagnosis that leads the visit.
Where do allergies live?
An allergy is recorded as an active-chronic diagnosis. It carries forward across visits like any other ongoing problem.
What happens to an earlier diagnosis when a later visit refers to it?
The later visit holds a read-only reference to the original, so the earlier diagnosis stays the single source and reads consistently across visits.
Read how the urgency of a presentation is ranked at triage.