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Confirm or remove a diagnosis

How to confirm an existing unconfirmed diagnosis by linking it to a clinical event, remove a diagnosis, and view removed or historical diagnoses.

Written by Connor Baeza

This article covers three related tasks: confirming a diagnosis that was previously recorded without a clinical event, removing a diagnosis from a patient's active record, and viewing the history of old or removed diagnoses.

Confirm an existing diagnosis

Use this when a diagnosis has already been recorded as unconfirmed (Linked Event column shows 0) and you now need to link it to a specific clinical event to confirm it.

  1. Access the patient's Diagnosis ICD10 screen and click Add Diagnosis.

  2. Select the Event Type, Event, and Event Instance from the dropdown boxes at the top of the screen.

  3. In the Client's diagnoses section (left panel), locate the existing unconfirmed diagnosis you want to confirm.

  4. Drag the existing diagnosis to the Selected Diagnosis panel on the right.

  5. Ensure the primary diagnosis is at the top and highlighted in green. Drag to reorder if needed.

  6. Click Save Diagnosis.
    Result: The diagnosis is now confirmed and linked to the selected event. The Linked Event column increments by 1.

Remove a diagnosis

📌Note: Removing a diagnosis does not permanently delete it. It is logically removed and remains visible via Show Removed Diagnoses. A removal reason and date are always recorded for audit purposes.

  1. Access the patient's Diagnosis ICD10 screen.

  2. Select the diagnosis you want to remove by clicking on it.
    Result: The background colour of the diagnosis changes to indicate it is selected.

  3. Click Remove Active Diagnosis.
    Result: The Remove a Diagnosis window is displayed.

  4. Select the required reason from the Reason for Removal dropdown list.

  5. Enter the date the diagnosis is being removed in the Date of Removal field.

  6. Enter any additional comments in the Removal Comments text box if required.

  7. Click Remove.
    Result: The diagnosis is removed and is no longer displayed on the active Diagnosis screen. It remains visible via Show Removed Diagnoses.

View old and removed diagnoses

  1. Access the patient's Diagnosis ICD10 screen.

  2. Click Show Removed Diagnoses.
    Result: The Diagnosis History screen is displayed showing both current and old or removed diagnoses.

  3. Click the + sign on the left of an old or removed diagnosis to display further details.
    Result: The removal reason, removal date, and removing user are displayed.

  4. Click Hide Removed Diagnoses to return to the current diagnosis view only.

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