If you haven't already:
Click Write (ALT+W).
Click General Care (ALT+G).
Click Diagnosis (ALT+G).
Physicians, nurse practitioners, physician assistants, certified nurse midwives, and medical students are prompted to enter the diagnosis record on writing new pre-admission or inpatient orders. For additional information, see Overview of the Diagnosis Record.
Complete the order:
Beginning with the primary diagnosis, and following with associated diagnoses as applicable, look up the diagnoses as follows:
Type at least the first three (3) letters of the diagnosis. For more than one associated diagnosis, you can type criteria for each, separated by commas. You can record only a single principal diagnosis.
Press ENTER or click Search. Diagnoses matching your criteria are listed on the right. Results are drawn from the Partners Enterprise Terminology Service.
To highlight a diagnosis for selection, click its line or press the down/up arrows. Highlight Take as typed to enter the diagnosis as you typed it. To highlight more than one item, hold down the CRTL key while clicking.
For associated diagnoses, multiple search parameters will generate multiple sets of results, one for each parameter. Select from one set of results (which may be None of the following) to be presented with the next.
To search using different criteria, click None of the Following, then repeat the previous steps.
Click Add (ALT+A) or press ENTER to select the highlighted diagnoses.
Repeat the process until all diagnoses applicable to this visit are listed.
Click OK (ALT+O).
Write additional orders as needed, then sign the session.