Diagnostic codes

Estimated reading: 6 minutes

Use the Diagnostic Code list to enter a diagnosis in a patient’s medical history to track patients with particular disorders and characteristics or for insurance billing. The AAHA diagnostic code list is provided for you.

Before you start

Security
  • Diagnostic Code List
  • Diagnostic Code Setup
  • Patient Diagnosis
  • Patient Diagnosis – Void

Important!

  • Diagnostic code ID’s cannot be modified once they are created.
  • Avoid creating duplicate diagnostic codes by searching the existing list. Select Search for word and Include inactives, before searching.
  • Once a diagnosis is added to a patient record, it cannot be changed or deleted.
    • Entries made in error can be voided. Example: Incorrect diagnosis

Setup a diagnostic codes

Navigate to Lists > Diagnostic Codes.

  1. Click New.
  2. Enter a Diagnostic Code. The code must begin with a letter and there is a maximum length of 9 alphanumeric characters.
  3. Enter a Hospital Description. There is a maximum of 60 alphanumeric characters/spaces.
  4. Select the Default Status as Tentative or Final. Status can be changed at the time of use.
  5. Link a document to print, if using.
    • Enter the document ID in the next blank Doc ID field or press F2 to search and select from the document template list.
    • Repeat as needed for additional documents.
  6. Click OK to save changes and return to the Diagnostic Code list.

Maintain diagnostic codes

Diagnostic codes can be inactivated or deleted, based on use with patient records.  Inactivated codes will be displayed in the list with an (I) when Include inactives is selected. A code’s status can be changed back to active, if needed.  Note: only active codes can be used as a diagnosis for a patient.

Update a diagnostic code

  1. Search the diagnostic code list by code or description to locate and select the diagnosis.
  2. Click Update.
  3. Modify the description, default status, code status, or linked documents as needed.
    • The code ID cannot be changed.
    • Changes to the description will be reflected in new patient diagnoses.
      • Past instances will not be changed.
      • Changes to descriptions should only be made to address spelling error or other minor updates.
    • Add a new document: The document ID in the next blank Doc ID field or press F2 to search and select from the document template list. Only active documents can be linked.
    • Change an existing linked document to a different document: Type over the Doc ID or F2 to search and select a different document.
    • Remove a document: Click in the Doc ID field and press Ctrl + D.
  4. Click OK to save changes or click Cancel to discard changes.

Delete an unused code

If the diagnostic code has not been used by your practice, you can delete it. Any diagnostic code that is a VPI code cannot be deleted.

  1. Search the diagnostic code list by code or description, to locate and select the diagnosis.
  2. Click Delete.
  3. Click Yes or No to confirm.
  4. If the code is used on a patient, click OK on the message.
    • Select Inactive, to inactivate the code instead.

Add/update diagnosis for a patient

Use diagnostic codes to enter tentative, ruled out, and final diagnoses in a patient’s medical history through a patient document or from the Patient Clipboard. If you enter a diagnosis in error, you can void it if you have security access.

Enter a new diagnosis

Navigate using any of the following:

  • Patient Clipboard > right-click patient > Diagnosis.
  • Within a patient document (medical note) > Click Add Diagnosis Description or Add Diagnosis Detail link.
  • Within a patient document (medical note) > Insert Diagnosis Description or Diagnosis Detail link.
  1. In the first available row, enter the diagnostic Code or press F2 to search and select a code from the Diagnostic Codes List.
    • A new code can added or a code can be update from the list, if needed. Security required is required to make these changes.
  2. The current date displays. Change the date to an earlier date, if needed.
  3. The default status displays. Modify as needed.
  4. If documents are linked to this diagnosis code, select Yes to print them.
  5. Enter the Staff ID of the doctor making the diagnosis.
  6. Repeat for additional diagnoses as needed.
    Note: Once you click OK, the diagnosis is added to patient’s medical history and cannot be changed or deleted. Entries made in error (incorrect patient or diagnosis) can be voided.
  7. Click OK.

Patient diagnoses can be viewed in patient history from the DX tab of the Patient Clipboard.

Change a diagnosis: Ruled our or final

Navigate to Patient Clipboard > right-click patient > Diagnosis.

  1. Do any of the following:
    • Click the down arrow next to the tentative status and select Final or Ruled Out. Click Yes or No to confirm.
    • Double-click the tentative diagnosis to update it to final. Click Yes or No to confirm.
    • Reenter the diagnostic code in the next available row and Click Yes or No to confirm.
  2. A new row will be created for the final diagnosis.
  3. Click OK.

Void a diagnosis

If you enter a diagnosis in error, you can void it if you have security access.


Navigate to Patient Clipboard > right-click patient > Diagnosis.

  1. Select the row for the diagnosis you want to void.
    Note: If a diagnosis was entered initially as Tentative and then updated to Final or Ruled Out, perform the void on the last diagnosis status. The related (Tentative) rows will also be voided.
  2. Click Void.
  3. In the Void Diagnosis window, enter your staff ID and press Tab.
  4. Enter a reason in the text box and do any of the following:
    • Click Spell Check to address any spelling errors.
    • Click OK to continue voiding the diagnosis. Click Yes or No to confirm.
    • Click Cancel to discard any changes and return to the Patient Diagnosis window.
  5. Click OK to save changes or click Cancel to discard changes and close the Patient Diagnosis window.

Additional information

General

Related reports

These Cornerstone reports provide information from the actions outlined in this article. Each report has its own security access under the Reports tab of the Security Setup window. 

  • Diagnostic Code Report
  • Diagnosis Count Report
  • Patient Diagnosis Report
Share this Page

Diagnostic codes

Or copy link

Jump to:
Feedback