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Add diagnoses to a client's record

Diagnoses live on the Diagnoses (ICD-10) card in the client profile sidebar. Add one by searching the code or the name (F41.1 or "anxiety"), mark one as primary, and save. They are encrypted at rest, copied into a new treatment plan, printed on superbills with pointer letters A, B, C in the order you list them, and included in chart exports.

Updated September 8, 20261 min read

Diagnoses are recorded once on the client's record and reused wherever they are needed.

Add or edit

  1. Open the client → Overview → the Diagnoses (ICD-10) card in the sidebar.
  2. Click Add diagnosis (or Edit).
  3. Search by code or by name — "F43.2" or "adjustment" — and pick the match; the description fills in.
  4. Mark one row as Primary with the star. If none is marked, the first row becomes primary.
  5. Save.

Remove a row with the ✕. The order of the rows matters for superbills (below), so list the primary diagnosis first.

Where they are used

  • Treatment plans start with the client's diagnoses copied in, shown read-only under "Diagnoses — from the chart". See Treatment plans.
  • Superbills print the diagnoses lettered A, B, C in card order, and each charge's diagnosis pointers refer to those letters. See Create and send superbills.
  • Charges carry pointer letters, never the codes themselves; pick them in the charge's Diagnosis pointers field. See Charges and the Billing tab.
  • Chart exports include a Diagnoses section. See Discharge and records release.

Good to know

  • Diagnosis codes and descriptions are encrypted at rest like the rest of the client's health information.
  • Any team member who can edit the client can edit diagnoses; the change is written to the audit trail.
  • Onset and resolved dates exist on the record but are not edited on this card.

Frequently asked questions

Where do the codes come from?
A built-in ICD-10 list matched to your practice type — a behavioral-health practice sees the F-codes, for example. Type a code or a word and pick from the matches; the description fills in.
Which diagnosis goes on the superbill?
All of them, lettered A, B, C in the order they appear on the card, and each charge points at the letters that apply. The primary flag is carried through but does not change the order, so put the primary diagnosis first.
Are diagnoses visible to the client?
Not on the portal by itself. They appear on a superbill the client downloads, in a chart export they request, and in a treatment plan they sign.

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