Physicians, nurse practitioners, physician assistants, certified nurse midwives, and medical students are responsible for recording the patient's diagnoses for this visit. These practitioners are prompted to enter the diagnosis record on writing new pre-admission or inpatient orders, if there is no current record. See Recording the Diagnosis for Admission.
The principal diagnosis is required; associated diagnoses should be recorded as needed. You can select "None" as the associated diagnosis.
Diagnoses from the inpatient record are listed on the face sheet for discharge, where you can edit as needed. Note that both the principal and associated diagnoses are required on the face sheet. See Completing the Face Sheet.
For some diagnoses, a selection of admission templates associated with the principal or associated diagnoses is offered after the diagnosis record is entered. See Selecting a Diagnosis-Based Template.