Scheduling Visit Tab

The Visit tab displays a variety of read-only visit information. Its child tabs allow the user to manage diagnosis and procedure information for the visit.

Diagnosis

The Diagnosis tab is used to add or delete diagnoses (admitting, final, or secondary) for the visit. The diagnoses indicate what a patient is being treated for and can work in conjunction with Medical Necessity Checking to verify the necessity of certain procedures.

While multiple diagnoses can be added, only one admitting and one final diagnosis are allowed on the visit. Secondary diagnoses have no limit.

Diagnoses can be added to the visit record by using existing diagnosis codes or by entering free-form text. Only admitting and secondary diagnoses can be added via free-form text.

To add a diagnosis, follow these steps:

1. Click the Add  button. A row is added to the list, and the Type dropdown menu defaults to:
   • Admitting – If there are no other diagnosis codes associated with the visit. This is the diagnosis/major complaint when the patient was admitted.
   • Final – If there is an admitting diagnosis code associated with the visit. This is the official diagnosis (if determined to be different from the admitting diagnosis), as determined by the facility’s personnel, and the issue treated.
   • Secondary – If there are admitting and final diagnoses codes associated with the visit. This is a diagnosis that is recorded for tracking but may not be related to the principal diagnosis.

2. Type – Click the drop-down and select a diagnosis type, if needed.
3. POA – Click the drop-down and select an option to identify if the diagnosis was present on admission.
4. Enter the diagnosis by one of the following methods:
   • Diagnosis. Enter a diagnosis code in the first field or a diagnosis description in the autocomplete field (clicking a suggested description to select it).

• • Freeform – Enter free-form text into the field.

• 5. Click Save.

Delete Diagnoses

To delete a diagnosis, follow these steps:

1. Click on a diagnosis in the list to select it.
2. Click the Delete button . The diagnosis is deleted from the list.
3. Click Save.

Procedure

The Procedure tab is used to add or delete procedure codes for a visit. Procedures can be added as principal or secondary, but a visit can only have one principal procedure. Procedures cannot be updated.

To add a procedure, follow these steps:

1. Click the Add  button. A row is added to the list, and the Procedure Information fields below are enabled. The Type dropdown menu will default to Principal if there are no procedures on the visit and Secondary if there is already a Principal type.

2. Type – Click the dropdown and select a procedure type (principal or secondary).
3. Procedure – Enter a procedure code in the first field or a procedure description in the autocomplete field (clicking a suggested description to select it). Date – This date defaults to the admit date. Click the field to enter the date directly or click to select a date from a calendar.

5. Click Save.

Delete Procedures

To delete a procedure, follow these steps:

1. Click on a procedure in the list to select it.
2. Click the Delete button . The procedure is deleted from the list.
3. Click Save.