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Clinical Records

Guide to managing diagnoses, conditions, and clinical documentation.

Overview

Clinical records module handles:

  • Diagnoses/Problems with ICD-10 autocomplete
  • Medical conditions tracking
  • Clinical status management
  • Severity classification
  • Onset and resolution dates
  • Clinical notes

Adding a Diagnosis

Step 1: Navigate to Problems

  1. Open patient record
  2. Click Problems tab in clinical navigation
  3. Click Add Diagnosis button

Step 2: Use ICD-10 Autocomplete

Diagnosis Name field with autocomplete:

  1. Start typing condition name (minimum 2 characters)
  2. Wait 300ms - dropdown appears
  3. See matching ICD-10 codes with descriptions
  4. Use keyboard (↑↓ arrows) or mouse to select
  5. Press Enter or click to select

Example: Type "diab"

┌─────────────────────────────────────────────┐
│ E11.9                                       │
│ Type 2 diabetes mellitus                    │
│ ICD-10-CM                                   │
├─────────────────────────────────────────────┤
│ E10.9                                       │
│ Type 1 diabetes mellitus                    │
│ ICD-10-CM                                   │
├─────────────────────────────────────────────┤
│ E11.65                                      │
│ Type 2 diabetes mellitus with hypergly...  │
│ ICD-10-CM                                   │
└─────────────────────────────────────────────┘

Code field auto-fills with selected ICD-10 code.

Time Saved

Autocomplete reduces coding time from 2-3 minutes to 10 seconds per diagnosis.

Step 3: Set Clinical Details

Category: - Encounter Diagnosis - Reason for this visit - Problem List Item - Ongoing condition - Health Concern - Patient worry/concern

Clinical Status: - Active - Currently affecting patient - Recurrence - Returned after remission - Relapse - Worsened after improvement - Inactive - No longer active - Remission - Controlled/in remission - Resolved - Completely resolved

Verification Status: - Confirmed - Definitively diagnosed - Provisional - Working diagnosis - Differential - Possible diagnosis - Refuted - Ruled out - Entered in Error - Incorrect entry

Step 4: Set Severity

Optional severity classification:

  • Mild - Minor impact
  • Moderate - Moderate impact
  • Severe - Significant impact

Step 5: Add Dates

Onset Date: - When condition started - Can be approximate

Abatement Date: - When condition ended - Only for resolved conditions

Step 6: Clinical Notes

Free-text field for: - Diagnostic criteria used - Treatment plan - Patient education provided - Follow-up needed

Step 7: Save

Click Save Diagnosis button.

Common Diagnoses Quick Reference

Chronic Conditions

Type Code Search Term
Type 2 Diabetes E11.9 diabetes, diabetic
Hypertension I10 hypertension, high blood
Asthma J45.9 asthma
COPD J44.9 copd, emphysema
Heart Failure I50.9 heart failure, chf
Atrial Fibrillation I48.91 atrial fib, afib
Hyperlipidemia E78.5 cholesterol, lipid

Acute Conditions

Type Code Search Term
Acute Bronchitis J20.9 bronchitis
Pneumonia J18.9 pneumonia
UTI N39.0 uti, urinary infection
Gastroenteritis K52.9 gastro, stomach flu
Migraine G43.909 migraine, headache
Acute Sinusitis J01.90 sinusitis, sinus

Mental Health

Type Code Search Term
Major Depression F32.9 depression
Anxiety Disorder F41.9 anxiety
PTSD F43.10 ptsd, trauma
Bipolar Disorder F31.9 bipolar

Problem List Management

Active Problem List

Purpose: - Current ongoing conditions - Guides treatment decisions - Affects prescribing - Insurance documentation

Best Practices: - Review at every visit - Update status changes - Resolve when appropriate - Keep list current

Inactive Problems

When to inactivate: - Condition resolved - Diagnosis refuted - No longer relevant

Don't delete - mark inactive to preserve history.

Clinical Status Workflow

graph LR
    A[New Diagnosis] --> B[Active]
    B --> C{Outcome?}
    C -->|Better| D[Remission]
    C -->|Worse| E[Relapse]
    C -->|Cured| F[Resolved]
    D --> G{Flare Up?}
    G -->|Yes| H[Recurrence]
    G -->|No| F

    style A fill:#14b8a6
    style B fill:#fbbf24
    style F fill:#10b981

Viewing Diagnoses

List View

Diagnoses table shows: - Condition name with ICD-10 code - Clinical status (badge) - Severity - Onset date - Last updated - Action buttons (Edit, Delete)

Filters: - Active only - By status - By severity - Date range

Sort by: - Condition name - Onset date - Last updated

Patient Overview

Summary of active conditions: - Problem list (top 5) - Chronic conditions - Recent diagnoses

Editing Diagnoses

Update Status

Common scenario: Condition improves

  1. Click Edit on diagnosis
  2. Change Clinical Status to "Remission"
  3. Optionally add Abatement Date
  4. Update clinical notes
  5. Save changes

Correct Errors

If wrong diagnosis entered:

  1. Edit diagnosis
  2. Change Verification Status to "Refuted"
  3. Add note explaining
  4. Save
  5. Add correct diagnosis

Don't Delete

Mark as "Entered in Error" instead of deleting. Preserves audit trail.

FHIR Condition Resource

Resource Example

{
  "resourceType": "Condition",
  "id": "condition-123",
  "clinicalStatus": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
        "code": "active"
      }
    ]
  },
  "verificationStatus": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
        "code": "confirmed"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-category",
          "code": "problem-list-item"
        }
      ]
    }
  ],
  "severity": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "24484000",
        "display": "Severe"
      }
    ]
  },
  "code": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/sid/icd-10-cm",
        "code": "E11.9",
        "display": "Type 2 diabetes mellitus without complications"
      }
    ],
    "text": "Type 2 diabetes mellitus"
  },
  "subject": {
    "reference": "Patient/patient-123"
  },
  "onsetDateTime": "2023-01-15",
  "note": [
    {
      "text": "Patient diagnosed following HbA1c of 8.2%. Started on Metformin 500mg BID."
    }
  ]
}

Documentation Best Practices

Diagnosis Entry

✅ Do: - Use ICD-10 autocomplete for accuracy - Document supporting evidence - Set appropriate clinical status - Add relevant notes - Review problem list at every visit

❌ Don't: - Enter unconfirmed diagnoses without marking provisional - Leave clinical notes empty - Forget to update status when condition changes - Delete diagnoses (mark inactive instead)

Clinical Notes

Include: - Diagnostic criteria met - Test results supporting diagnosis - Differential diagnoses considered - Treatment plan - Patient education provided - Follow-up schedule

Example: 

Type 2 diabetes mellitus diagnosed based on:
- Fasting glucose 142 mg/dL (confirmed x2)
- HbA1c 7.8%
- BMI 32 (obese)

Started Metformin 500mg BID with meals.
Provided diabetes education materials.
Referred to dietitian for nutrition counseling.
Follow-up in 3 months with repeat HbA1c.

Integration with Other Modules

Affects Prescriptions

Active diagnoses: - Show in prescribing context - Support clinical decision making - Justify medication orders - Required for some insurance approvals

Affects Encounters

Diagnoses link to encounters: - Primary reason for visit - Secondary conditions addressed - Differential diagnoses considered

Affects Billing

ICD-10 codes required for: - Insurance claims - Procedure justification - Level of service determination

Common Workflows

New Chronic Disease Diagnosis

graph TD
    A[Abnormal Lab/Symptoms] --> B[Diagnostic Tests]
    B --> C[Confirm Diagnosis]
    C --> D[Add to Problem List]
    D --> E[Status: Active]
    E --> F[Category: Problem List]
    F --> G[Start Treatment]
    G --> H[Patient Education]
    H --> I[Schedule Follow-up]

    style D fill:#14b8a6
    style G fill:#14b8a6

Acute Illness Resolution

graph TD
    A[Diagnosis Added] --> B[Treatment Started]
    B --> C[Symptoms Improve]
    C --> D[Condition Resolved]
    D --> E[Edit Diagnosis]
    E --> F[Status: Resolved]
    F --> G[Add Abatement Date]
    G --> H[Document Resolution]

    style F fill:#10b981

Next Steps