In Rio, you can record a diagnosis in two ways: linked to a specific clinical event (confirmed), or without an event (unconfirmed). Use the scenario below that matches your situation.

📌Note: You must have access to the Diagnosis ICD10 screen to record diagnoses. If you cannot find this in your menu, contact your system administrator.

Record a diagnosis with a clinical event (confirmed)

Use this scenario when you are recording a new diagnosis and linking it to a specific clinical event at the same time. For example, at the point of a CPA Review, referral, or inpatient episode.

⚠️Important: Once a diagnosis is saved to a clinical event, it becomes a confirmed diagnosis and its additional details cannot be changed. Verify all details before clicking Save Diagnoses.

Access the patient's Diagnosis ICD10 screen from the appropriate menu. Select the patient in the usual way.
Result: The Diagnosis screen is displayed showing any current diagnoses.
Click Add Diagnosis.
Result: The Add Diagnosis window is displayed. The Client's diagnoses section shows all previously added diagnoses.
Select the Event Type from the dropdown list (for example, Finished Consultant Episode, CPA Review, or Referral).
Result: The Event dropdown appears.
Select the Event from the dropdown list.
Result: If the event can have multiple confirmations, the Event Instance dropdown appears.
If displayed, select the Event Instance. If the Event Instance is UFCE or Referrals, a Confirmation Date must also be selected.
To add a new diagnosis: enter the ICD-10 code or description in the Add Additional Diagnosis field. Related codes and descriptions are listed below as you type.
Select the correct diagnosis from the list of possible matches.
Result: The chosen diagnosis is highlighted. If SNOMED CT access is enabled, matching SNOMED clinical terms are displayed in the Search Results column.
If SNOMED terms are displayed, select the correct clinical term from the Search Results column.
Select the relevant term from the SNOMED Concept Hierarchy column, expand or contract the hierarchy using the arrow symbols to find the most specific term.
Drag the highlighted diagnosis to the Selected Items column on the right.
Result: The diagnosis appears in the Selected Diagnosis panel.
Ensure the primary diagnosis is at the top of the Selected Diagnosis column (highlighted in green). Drag to reorder if needed.
To add additional details: check the checkbox on the right of the selected diagnosis and click Add Additional Details. Complete the following fields:
- Date of Diagnosis: Automatically set to today; update if needed.
- Condition Onset Date: The date the condition first began.
- Fetal Diagnosis: Check if the diagnosis was made during pregnancy.
- Comments: Any additional clinical notes. Click Update.
Click Save Diagnoses.
Result: A confirmation pop up appears. Click OK. The diagnosis is saved as a confirmed diagnosis linked to the selected event. The Linked Event column shows 1.

📌Note: The diagnoses available depend on the event type selected. For example, FCE returns diagnoses active on the transfer or discharge date plus 28 days; CPA Review returns diagnoses active on the review date plus 28 days. The number of days may vary by local configuration.

Record a diagnosis without a clinical event (unconfirmed)

Use this scenario when you need to record a working or provisional diagnosis that is not yet linked to a specific clinical event. The diagnosis can be confirmed later.

Access the patient's Diagnosis ICD10 screen and click Add Diagnosis.
Leave the Event Type as None, do not select an event type.
Enter the ICD-10 code or description in the Add Additional Diagnosis field and select the correct diagnosis from the results.
If SNOMED CT access is enabled, select the appropriate SNOMED term from the Search Results and Concept Hierarchy columns.
Drag the diagnosis to the Selected Items column. Add additional details if required.
Click Save Diagnoses.
Result: The diagnosis is saved as an unconfirmed diagnosis. The Linked Event column shows 0. The diagnosis appears in the Client's diagnoses section and can be linked to an event to be confirmed at a later date.

🤓Tip: To confirm an unconfirmed diagnosis later, see the article: Confirm or remove a diagnosis.