The Diagnoses tab in client records enables providers to track current and past diagnoses for clients. CAREWare uses ICD-10 diagnosis codes which are activated under Clinical Setup.

Add a Diagnosis to a Client Record

1. Click Diagnoses.

2. Click All Diagnoses.

3. Click Add.

View: View an existing diagnosis record.

Add: Add a new diagnosis record.

Delete: Delete an existing diagnosis record.

Back: Return to the Client Diagnoses menu.

Print or Export: Print or export the list of diagnoses.

Hide/Show Columns: Hide or show columns in the list of diagnoses.

 

4. Enter the date of the diagnosis.

5. Search for the diagnosis in the ICD10 Code/Description box. Diagnoses can be located with the name of the diagnosis or the ICD-10 code.

 

6. Select the diagnosis.

7. Complete the fields for Diagnosis Details, Assessment (Definitive, Presumptive, or Unknown), Status (Active, Inactive, or Resolved), Date Resolved, and Comment.

8. Click Save.

 

Review Active Diagnoses for a Client

Users can review a more limited list of only active diagnoses for a client. The list of diagnoses under All Diagnoses shows active, inactive, and resolved diagnoses.

 

To review only active diagnoses, click Active Diagnoses.

The list is limited to diagnoses with active status.

View: View details for the diagnosis record.

Back: Return to the Client Diagnoses menu.

Print or Export: Print or export the list of active diagnoses for the client.

Hide/Show Columns: Select which columns to hide or show in the list of active diagnoses.