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Assigning Diagnosis Codes (article)

Summary:

Diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs & chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses, and injuries into codes from a particular classification. PIMSY includes ICD-9 and ICD-10 codes for Mental Health diagnoses.

An update (April 18, 2017) to this article is available HERE. The article is on Diagnosis Codes on Released Notes.

Buttons:

New Diagnosis – select a new diagnosis for the selected client.

View Diagnosis – view the selected diagnosis details.

Educational Resources – depending on which codes are selected, this link will send you to resources for diagnosis codes on the MedlinePlus Connect website managed by the U.S. National Library of Medicine. Not all codes in PIMSY can be found on the MedLinePlus website.

WHODAS - World Health Organization Disability Assessment Schedule. A generic assessment instrument for health and disability; a tool to produce standardized disability levels and profiles; applicable across cultures and in all adult populations; directly linked at the level of the concepts to the International Classification of Functioning, Disability and Health (ICF).

Checkboxes:

Show Family – view the diagnosis code family

Show History – view the history of the code selected

Columns:

Code – the code number.

Name – the name of the code.

Description – a description of the code.

Diagnosis Date – the start date for this diagnosis

GAF/CGAF – the Global Assessment of Function and Children’s Global Assessment of Function

Diagnosis - the diagnosis for the selected client.

Status – an indication of whether the code is Active, Inactive or Resolved.

Resolved Date – if appropriate, the date the diagnosis was resolved.

InActive Date – an indication the selected code is inactive in the client’s chart.

Present On Admission - indicates whether the client was present or not during admission. The checkbox is in the New Diagnosis box.

Reviewed Date - date Diagnosis was reviewed

Diagnosis By - person who created the Diagnosis

Note # - the note number associated with the selected code in the client’s chart.

Code Type – the type of code: ICD 9, ICD 10, DSM 5/ICD-10

Order – the order of the codes in the diagnosis, usually according to severity.

Last Edited Date – the date the selected code was last edited.

Last Edited By – the person who last edited the code.

Created Date – the date the diagnosis was created.

Created By – the person who created the diagnosis.

Instructions:

Go to the Client’s chart and click on the Diagnosis tab. Click on the New Diagnosis button to begin the selection of codes for this diagnosis.

When you have selected a code and completed all relevant information, click Save. The code is now added to the client’s chart.

Use Case:

Joe the therapist has just seen a new patient and must prepare a diagnosis in his chart. Joe goes to the client’s chart and selects the Diagnosis button.

From the client’s diagnosis, Joe can select codes, view diagnoses, consult educational resources on codes, and export a diagnosis to Excel.

Related Articles:

If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3.

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