Diagnoses, medications, and allergies
Record diagnoses, medications, allergies, supplements, and No known allergies from the patient Summary or while charting a visit. Review details, edit clinical fields, and archive records that should no longer appear in the active chart.
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. Use the sections in the screenshot to move around the page: Diagnoses (1) and Allergies (3) are record sections, Add diagnosis (2) opens the diagnosis dialog, and Medications (4) is the medication section. 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?
In the left sidebar, click Patients, then click the patient's name. In the patient chart menu, click Summary. If you are charting a visit, click Visits in the left sidebar, then click the visit. Use the Diagnoses section to add the diagnosis where it belongs on the chart. Use Search by name or ICD-10 code (1), Custom entry (2), a matching code row (3), Billable or not billable (4), and Next (5).
- Select Add diagnosis in the Diagnoses section.
- Search by condition name or ICD-10 code (1), or browse the categories.
- Choose a matching code (3). If the row is Not billable (4), choose a more specific billable code before continuing.
- If the diagnosis is not listed, use the custom entry option (2).
- Select Next (5).
- Choose Certainty. Use Provisional (working) while you are still working it up, or Differential (rule out) when it belongs on a rule-out list.
- 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?
In the left sidebar, click Patients, then click the patient's name. In the patient chart menu, click Summary. On the same page, choose the most specific product you can when the strength and form are known. The screenshot shows the medication and supplement sections side by side: Medications (1) and Supplements (3) are the section headings, while Add medication (2) and Add supplement (4) open the two dialogs.
To add a medication:
- Select Add medication in the Medications section.
- Search for a brand or generic name.
- Choose the name, then choose a strength and form when the picker shows them.
- If you need to chart the name without a strength, choose the option to chart it without a strength.
- If the medication is not listed, continue with a custom entry.
- Select Next.
- Choose Status. New medications default to Active; other options include Intended, On hold, Completed, Stopped, and Not taken.
- Add dosing details as needed: Route, Dose amount, Dose unit, Frequency, Start date, End date, Instructions, and Note. Select Add medication.
On the same page, to add a supplement:
- Select Add supplement in the Supplements section.
- Search for a supplement product, or continue with a custom entry when the supplement is not listed. Results are ordered by best match, so a product can appear above an ingredient when that is the closer match.
- Select Next.
- Choose Status.
- 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?
In the left sidebar, click Patients, then click the patient's name. In the patient chart menu, click Summary. On the same page, use No known allergies only when the patient has no real allergies recorded. In the screenshot, Allergies (1) is the section heading, Add allergy (2) opens the allergy dialog, and mark no known allergies (3) records that there are none.
To add an allergy:
- Select Add allergy in the Allergies section.
- Search for an allergen. Results are grouped as Medications and Foods, environmental & other substances.
- Choose a result, or use a custom entry when the allergen is not listed.
- Select Next.
- Choose Type and Category. Add Severity, Criticality, Onset date, Reactions, and Note if known.
- Select Add allergy.
On the same page, 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?
On the same page, review a record by hovering over its pill on desktop or tapping it on a touch device. The detail card shows the coded and clinical details without opening an edit form. The numbered callouts show the code list (1), the recorded details area (2), and the actions you can use from the card: Archive (3) and Edit (4). When pending AI suggestions exist, the section also shows a review row with a count and Confirm all / Dismiss all for bulk review; use that row when you want to clear the section's suggestions without opening each pill one by one.
The top of the card shows the record name. Codes (ICD-10, SNOMED) (1) lists the codes. Recorded, status, severity, onset and note (2) shows the fields that apply to that record. Archive (3) and Edit (4) are the actions at the bottom.
Use Edit (4) when the clinical details need to change. Use Archive (3) when the record should no longer appear in the active chart. On archived patients, the pill action bar hides edit, archive, AI review, and visit-link actions.
How do I edit or archive a record?
In the left sidebar, click Patients, then click the patient's name. In the patient chart menu, click Summary. On the same page, edit a record when the clinical details have changed. Archive it when the record should no longer appear in the active chart. In the screenshot, Codes (1) shows the record's coding, Recorded, status, severity, onset and note (2) shows the detail grid, and Archive (3) and Edit (4) are the actions at the bottom. If the section has pending AI suggestions, use the review row above the pills first if you want to confirm or dismiss them in bulk.
- Hover over the record's pill on desktop or tap it on a touch device to open the details panel.
- Select Edit.
- Change the fields the edit form allows.
- 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 on desktop or tap it on a touch device to open the details panel, select Archive, then confirm the archive action. The record is removed from the active section. On archived patients, those action-bar controls are hidden on diagnosis, medication, allergy, and supplement pills.
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.
- On archived patients, the pill action bar hides edit, archive, AI review, and visit-link actions for diagnosis, medication, allergy, and supplement pills.
- When a section shows pending AI suggestions, the bulk review row appears only for the section's pending suggestions, not for archived patients.
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.
How do I review a whole section's AI suggestions?
Use the section-level review row when it appears. It shows the suggestion count and gives you Confirm all or Dismiss all for the pending records in that section.
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