Diagnoses are recorded once on the client's record and reused wherever they are needed.
Add or edit
- Open the client → Overview → the Diagnoses (ICD-10) section of the Clinical card in the right-hand column.
- Click Add diagnosis (or Edit).
- In Search by code or description, type a code or a word ("F43.2" or "adjustment") and pick the match; the description fills in. Click Add diagnosis again for another row.
- Click Set primary (the star) on the main diagnosis; it then reads Primary. If none is marked, the first row becomes primary.
- Click Save (or Cancel to discard).
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, marked "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 HIPAA Audit Log (Settings → Account Activity).
- Onset and resolved dates exist on the record but are not edited on this card.