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.
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:
To delete a diagnosis, follow these steps:
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:
To delete a procedure, follow these steps: