Diagnoses, medications, and allergies

Diagnoses, allergies, medications, and supplements live on the patient Summary. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. The same record sections can also appear while charting a visit, so you can add a record directly to that visit.

Adding a medication or supplement here records it on the patient's chart. Prescribing is a separate workflow. See Sending a prescription.

How do I add a diagnosis?

Add a diagnosis from the patient Summary when it belongs on the patient's chart. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. In a visit, click Visits in the left sidebar, click the visit, then use Add diagnosis when the diagnosis is part of that visit.

1. Select Add diagnosis in the Diagnoses section.
2. Search by condition name or ICD-10 code (1), or browse the categories.
3. Choose a matching code (3). If the row is Not billable (4), choose a more specific billable code before continuing.
4. If the diagnosis is not listed, use the custom entry option (2).
5. Select Next (5).
6. Choose Certainty. Use Provisional (working) while you are still working it up, or Differential (rule out) when it belongs on a rule-out list.
7. Add Severity, Onset date, and Note if they matter, then select Add diagnosis.

The diagnosis appears as a pill in the Diagnoses section. If you add it during a visit, it is saved with that visit.

How do I add a medication or supplement?

Add a medication or supplement from the patient Summary when you need it on the patient's chart. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. Choose the most specific product you can when the strength and form are known.

To add a medication:

1. Select Add medication in the Medications section.
2. Search for a brand or generic name.
3. Choose the name, then choose a strength and form when the picker shows them.
4. If you need to chart the name without a strength, choose the option to chart it without a strength.
5. If the medication is not listed, continue with a custom entry.
6. Select Next.
7. Choose Status. New medications default to Active; other options include Intended, On hold, Completed, Stopped, and Not taken.
8. Add dosing details as needed: Route, Dose amount, Dose unit, Frequency, Start date, End date, Instructions, and Note. Select Add medication.

To add a supplement:

1. Select Add supplement in the Supplements section.
2. Search for a supplement product, or continue with a custom entry when the supplement is not listed.
3. Select Next.
4. Choose Status.
5. Add dosing details, dates, and Note as needed, then select Add supplement.

You can also add supplements by applying a supplement template from the Supplements section.

When you choose a medication or supplement product with known details, the form can prefill fields from that product. You can change those details before saving.

How do I add an allergy or No known allergies?

Add allergies from the patient Summary so they are visible on the chart. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. Use No known allergies only when the patient has no real allergies recorded.

To add an allergy:

1. Select Add allergy in the Allergies section.
2. Search for an allergen. Results are grouped as Medications and Foods, environmental & other substances.
3. Choose a result, or use a custom entry when the allergen is not listed.
4. Select Next.
5. Choose Type and Category. Add Severity, Criticality, Onset date, Reactions, and Note if known.
6. Select Add allergy.

To record that the patient has no known allergies, select mark no known allergies from an empty Allergies section, or select Add allergy and then No known allergies in the dialog.

No known allergies is only offered when the patient has no real allergies recorded and does not already have a No known allergies record.

How do I review the details on a record?

Review a record from the patient Summary by hovering over its pill. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. The detail card shows the coded and clinical details without opening an edit form.

The top of the card shows the record name. Coded records show their codes (1). The details area shows the fields that apply to that record (2): diagnoses show status, severity, certainty, onset, resolved date, and note; allergies show type, category, severity, criticality, status, onset, note, and reactions; medications show type, status, start and end dates, dosage, reason, and note; supplements show source, status, started and ended dates, dosage, note, and supplement facts. Supplement detail cards can also show View label on DSLD.

Use Edit (4) when the clinical details need to change. Use Archive (3) when the record should no longer appear in the active chart.

How do I edit or archive a record?

Edit a record from the patient Summary when the clinical details have changed. In the left sidebar, click Patients, click the patient's name, then click Summary in the patient chart menu. Archive it when the record should no longer appear in the active chart.

1. Hover over the record's pill.
2. Select Edit.
3. Change the fields the edit form allows.
4. Select Save changes.

Diagnosis edits include Status, Severity, Certainty, Resolved date, and Note. Allergy edits include Status, Severity, Criticality, and Note. Medication edits include Status, dosing fields, dates, Instructions, Note, and Change for choosing a different medication. Supplement edits include Status, Change for choosing a different supplement, dosing fields, dates, and Note.

To archive a record, hover over the pill, select Archive, then confirm the archive action. The record is removed from the active section.

What can't I do here?

• You cannot add records from a read-only chart view.
• You cannot add a non-billable ICD-10 diagnosis from the coded picker. Choose a more specific billable code before selecting Next.
• You cannot edit the diagnosis code or allergen after saving. Archive the record and add a new one if the coded concept is wrong. Medication and supplement products can be changed from the edit form.
• You cannot edit No known allergies into a real allergy. Archive No known allergies if it was recorded in error.
• You cannot record No known allergies when the patient already has real allergies recorded.

Common questions

Can I add a custom diagnosis, medication, supplement, or allergy?

Yes. Diagnosis, medication, supplement, and allergy pickers let you continue with the text you typed when the coded result is not available. Custom entries may not have ICD-10, SNOMED, RxNorm, or supplement product codes.

Why does a diagnosis say Not billable?

Some ICD-10 rows are categories or less-specific codes. Pick a more specific billable code before selecting Next.

Can I use this to prescribe a medication?

No. Adding a medication or supplement records it on the chart. Use the prescribing workflow for prescriptions. See Sending a prescription.

Can I see medication history from outside the charted list?

Medication history is a separate view. See Viewing a patient's medication history.

Can I open a supplement label from the detail card?

Yes, when the supplement detail card shows View label on DSLD.

Why don't I see No known allergies?

No known allergies is hidden when the patient already has a real allergy recorded or already has a No known allergies record.