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iEHR Preconfigured Section - Encounter Diagnosis

The Coding Care Slip section sets Diagnosis and Charge codes for the patient's visit, and create a Care Slip order.

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Tap the Diagnosis list header to search for diagnosis codes from the Add Diagnosis menu. From the on screen keyboard, type at least three characters and tap the Search button. If the diagnosis code is not a search result, the diagnosis code will need to be added to the Diagnosis node within the Reference ability in MacPractice. If the diagnosis code is found in the search, tap the diagnosis code result to add it to the patient's Diagnosis list.

Tap the Charge list header to search for procedure code from the Add Charge menu. From the on screen keyboard, type at least three characters and tap the Search button. Any procedure code within any fee schedule in the MacPractice database will be searched. If the procedure code is not a search result, the procedure code will need to be added to a fee schedule in the Fee Schedule node within the Reference ability in MacPractice. If the procedure code is found in the search, tap the procedure code result to add it to the patient's Charges list.

With the charge and diagnoses added, tap the Associate Dx button to associate a diagnosis code to each charge. Select a diagnosis code from the Associate Diagnosis menu, which displays the diagnoses in the Diagnosis list within the Coding section.

Once finished, tap the Create Billing Order button to create a billing order for the charges and diagnoses listed. The orders will be assigned to the logged in iEHR user and appear as EHR CareSlip Orders in the Orders tab of the Patient ability. For more information on CareSlip Orders, see EMR CareSlip.

The Coding Care Slip section is not designed to pull data forward.

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Comments

  • Avatar
    Leighton Heusinger

    Some images would be helpful in this article. You can even link it to the interactive EHR form.

  • Avatar
    Roger Crum

    This article needs updating.

    The article title references the current Encounter Diagnosis element available in iEHR, but the content reflects the Coding Care Slip element, which was supplanted by the current element (albeit, confusingly, with a different name at the time (Assessment)) on release of 5.0. The coding care slip element hasn't even been available in the software since 4.4.

    Further, there are no images.

    The article for EHR Preconfigured Section - Encounter Diagnoses is better representative of what the current element is, though that article has screenshots specific to the desktop element. However, this article came up first for me in a search for "encounter diagnosis", meaning the first link clients see when searching for this will be the inaccurate one.