Procedure
Record a diagnosis
Record a diagnosis on the patient record in Atlas, choose the coded term, and add the detail that supports later care and billing.
Record a diagnosis on the patient record in Atlas, choose the coded term, and add the detail that supports later care and billing. A visit carries a diagnosis before you place orders on it, so this is the step that opens the ordering card.
Diagnosis comes before orders
Until a visit carries a diagnosis, the ordering card shows Add Diagnosis First in place of the order form. Recording one here opens ordering for the visit.
Record a diagnosis
- 1
Open the diagnosis panel
On the info-bar spine, tap the primary diagnosis. The diagnosis panel opens and lists the diagnoses already on the visit. If the chip reads
No diagnosis, the panel opens ready for the first one. - 2
Search for the coded term
In Fill new, type the condition. The terminology search returns coded terms as you type; choose the one that fits. The coded term the record keeps is the ICD-11 code, and you add one or more codes to the diagnosis you are preparing.
- 3
Confirm the detail
Confirm the diagnosis attributes. They arrive pre-set to sensible values, so you review and adjust rather than fill from blank. This is the detail that supports later care and reads on the bill.
- 4
Save the diagnosis
Choose Confirm. Atlas writes the diagnosis once the entry is complete, so a half-filled diagnosis stays out of the record. The first diagnosis of the visit is set as the
primary, and it appears on the info-bar chip. - 5
Reference an earlier condition where it applies
To carry an existing condition into this visit, choose Reference older and pick from the patient's active and chronic diagnoses. Atlas records a pointer to the earlier entry and shows it in its original form, so the source diagnosis stays as it was.
The primary diagnosis
A visit carries one primary diagnosis. To make a different diagnosis primary, mark it on the panel; Atlas promotes it and moves the previous primary to secondary in the same step. The info-bar chip always shows the current primary, so the front of the record reads true.
coded term ICD-11 Required | At least one code, chosen from the terminology search. |
type primary or secondary Required | The first diagnosis of a visit defaults to primary. |
status active, active-chronic, resolved, ruled-out Required | Set from the legal values for the diagnosis. |
detail attributes | The clinical attributes confirmed at entry. |
The coded term does the work later
The coded term is what makes the diagnosis legible across sites and on the bill. Choosing it here, rather than typing free text, is what lets billing, analytics and a clinician at another site read the same condition. Allergies live as diagnoses too, in the allergy range of the coded terms, so they show on the allergy strip.
Editing and history
An earlier active diagnosis can be edited, for example to mark a chronic condition resolved, behind a confirm step. A referenced diagnosis stays read-only, since it belongs to its own visit. Every attribute change is kept as a trail on the panel, so the record shows how the diagnosis moved over time.
Common questions
Can a visit carry more than one diagnosis?
Yes. A visit carries several diagnoses, with exactly one marked primary and the rest secondary.
What is the difference between Fill new and Reference older?
Fill new creates a diagnosis for this visit from the coded term. Reference older points to an existing active or chronic diagnosis and keeps it in its original form.
I picked the wrong code before confirming.
Adjust the codes on the entry before you confirm. Atlas writes the diagnosis only when you confirm a complete entry, so the change stays with you until then.
Place an order now that the visit carries a diagnosis.