Inactivate a Problem/Diagnosis

Certain problems/diagnoses may occur that become inactive, but have not become fully resolved. For example, a patient may have Tuberculosis that is now in remission and the user does not want that diagnosis in the Problem/Diagnosis List in the Face Sheet. These types of diagnoses can be inactivated and be transferred to the Inactive Diagnosis List in the patient's Face Sheet. Use the following steps to inactivate a diagnosis.

 

 

  1. Open a patient's chart note.
     

  2. Click the Open Diagnosis Checklist button in the checklist bar to access the Diagnosis checklist.



     

  3. In the left pane of the Diagnosis Checklist,  in the Chart Diagnoses section, click the Note Diagnosis   button next to the diagnosis you would like to inactivate.



     

  4. In the Note Diagnosis dialog, the diagnosis that you want to inactivate will appear in the dialog box. If this is not the diagnosis you want to inactivate, click the Cancel button.
     

  5. Select an Action for the diagnosis, if applicable.
     

  6. In the Observation Noted section, check any applicable Observation as needed.
     

  7. Check the Inactivate option and configure the Date on which this diagnosis is inactive.
     

  8. Click the Yes radio button under the Apply Last Comment option if you would like the last comment made from the preceding note to populate in the Comments field.

    NOTE: The Yes option will default if the Apply Last Diagnosis Comment option is selected in the General preferences.

    NOTE: Clicking the No option will remove any defaulted comment that has been populated from a preceding note. Likewise, you also have the ability to click the Yes option, read the note for reference, and then click the No option no remove the previous comment, and then add a new comment if needed.



     

  9. The SNOMED section of the Note Diagnosis List dialog allows you to map the diagnosis code to the applicable SNOMED CT code. When mapping diagnosis codes to SNOMED CT codes, there are three types of mapping that can take place: mapped, multiple mappings are available, and no mappings are available.

    When a diagnosis code is mapped directly to a SNOMED CT code, the diagnosis will be listed in the Item Description column, and the applicable code will appear in the SNOMED column and a disclaimer will be displayed below. You have the ability to remove the SNOMED code by highlighting the code, and then clicking the Delete button. You also have the ability to search for different or additional SNOMED codes by clicking the Search button. Once the applicable SNOMED codes are attached to the diagnosis, you can set the SNOMED code or codes as a default for that diagnosis by clicking the Save button. When multiple SNOMED codes are available you have the ability to decide which codes will be attached for this particular instance of the diagnosis by checking, or unchecking, the corresponding Apply field without disrupting the default setting for subsequent iterations of that diagnosis.

    When a diagnosis code has multiple SNOMED CT codes that it can be mapped to, "Multiple mappings are available" will be displayed above the Disclaimer. Click the Search button to search for the applicable SNOMED codes. In the Search List dialog, the Category field lets you search National Library of Medicine Suggested Mappings, or <All> SNOMED codes. The former category option will default when multiple mappings are available. Once the applicable code or codes are selected they will appear in the SNOMED column. As before, you can remove a SNOMED code by highlighting it, and clicking the Delete button; you can set the SNOMED code or codes as a default for that diagnosis by clicking the Save button; and when multiple SNOMED codes are available you have the ability to decide which codes will be attached for this particular instance of the diagnosis by checking, or unchecking, the corresponding Apply field without disrupting the default setting for subsequent iterations of that diagnosis.

    When a diagnosis code has no mappings available, No mappings are available" will be displayed above the Disclaimer. Click the Search button to search for the applicable SNOMED codes. Once the applicable code or codes are selected they will appear in the SNOMED column. As before, you can remove a SNOMED code by highlighting it, and clicking the Delete button; you can set the SNOMED code or codes as a default for that diagnosis by clicking the Save button; and when multiple SNOMED codes are available you have the ability to decide which codes will be attached for this particular instance of the diagnosis by checking, or unchecking, the corresponding Apply field without disrupting the default setting for subsequent iterations of that diagnosis.
     

  10. In the Comments field, enter or modify any free-text Comments concerning the inactivation of this diagnosis if needed. Do note, there is a 1020 character limit to this field.
     

  11. When finished, click the OK button. The diagnosis will now be moved from the Active Diagnosis list in the Chart Diagnosis section of the left pane of the Diagnosis checklist, to the Inactive Diagnosis list in the Encounter Diagnosis section of the left pane of the Diagnosis checklist.
     

  12. When all the applicable changes have been made, click the OK button in the Diagnosis checklist. The diagnosis will be transferred from the Problem/Diagnosis List to the Inactive Diagnosis List in the patient's Face Sheet. Likewise, the diagnostic event will be tracked in the History tab.