Using Diagnosis Assignments

Diagnosis Assignments allow you to enter and finalize a patient’s diagnosis following your standards of care, regulatory, and billing requirements.

About Diagnosis Assignments

A patient’s diagnosis, based on history, symptoms, and DSM-5, is recorded as a Diagnosis Assignment in a patient’s mental health and substance-use record. Because a Diagnosis Assignment is an important factor in determining care, compliance, and reimbursement, it is required to have a Diagnosis Assignment (even if provisionally) in place before processing an Appointment Record.

Location of Diagnosis Assignments

In ClinicTracker, there are a few places to view, create, edit, and lock a Diagnosis Record:

• Appointment Records

• Quick Info Pane (QIP)

• DSM Tab of a Form or Progress Note

Viewing Diagnosis Assignment

• Go to the Diagnosis Assignment section of an Appointment, QIP, or DSM Tab.

• The current Diagnosis Assignment will be displayed.

• Click the View button.

• Previous Diagnosis Assignments may be selected from the dropdown and displayed.

Creating a New Diagnosis Assignment

• Go to the Diagnosis Assignment section of an Appointment, QIP, or DSM Tab.

• Click the New button.

• You will be allowed to load information from the latest diagnosis.

• Select the Assigning Staff from the dropdown.

• Select the Date Recorded (defaulted to today).

• Select the Effective Dates.

• Use the Green + button to open the DSM-5 Guide Diagnosis Search.

• Enter a search term and click Search.

• Highlight the desired diagnosis.

• Add Additional Coding Information:

  • Coding Note

  • Additional Comments

  • Present on Admit

  • Mark if Provisional

• Select any Onset Specifiers.

• Click Select.

• Click on the Locked checkbox to lock the Diagnosis Assignment.

• Click Save.

• You will have the option to end any existing Diagnosis Assignments.

Editing an Unlocked Diagnosis Assignment

• Go to the Diagnosis Assignment section of an Appointment, QIP, or DSM Tab.

• Click the Edit button.

• Make the desired changes.

• Click on the Locked checkbox to lock the Diagnosis Assignment.

• Click Save.

Deleting a  Diagnosis Assignment

• If you’ve made a mistake and need to delete a Diagnosis Assignment.

• Go to the Diagnosis Assignment section of an Appointment, QIP, or DSM tab.

• For Locked Records: Click the View button > File > Delete.

• For Unlocked Records: Click the Edit button > File > Delete.

• You will be asked to confirm the deletion.

Allowing Multiple/Overlapping Diagnosis Assignments at Once

• Go to Admin Config > General: Clinic Information > Allow Overlapping Diagnosis Assignments.

Quick Info Pane