Master Problem List, SOAP Problems, and Diagnoses

 Objective

Update the workflow of Diagnosis to combine with MPL and SOAP Problems. Diagnosis will be auto added and linked to the MPL, in a similar workflow as SOAP problems and the MPL. Diagnoses will also be automatically added from Requests, like Radiology, Biopsy, Cytology, etc. Diagnoses added through request will always default to secondary on the episode and corresponding MPL entry.

 Requirements

 User interaction and design

Patient Summary

Displays the active problems and diagnoses. New column to display a link to the medical record area the problem or diagnosis originate from. Diagnosis Type displays both if the diagnosis is definitive or presumptive and if the diagnosis is primary or secondary.

Open

Visits (Episode) Diagnosis View/Entry

Update the diagnosis list to be cleaner and more like other areas in the medical record. Move the search function to a dialog box for the single diagnosis being added or edited.

Open

Add Diagnosis to Requests

Add the ability to link diagnosis to hospital requests, like laboratory tests. Create a new report info type “Diagnosis Coding” that allows for adding diagnosis to a request or add a diagnosis to the episode if used on a document. The diagnoses added to the request will automatically be added to the episode and by default flow into the MPL. Diagnosis from requests or lab tests will default secondary definitive type, but can be updated to a primary diagnosis and commented on. There will also be an option to not propagate the diagnosis to the MPL if desired.

Add Diagnosis to SOAP Problem List

Add the ability to add a diagnosis as a problem in the SOAP problem list. This would allow for soaping a diagnosis like a problem. If a diagnosis is added to the problem list, it will automatically be added as a diagnosis at the episode level and propagate up to the MPL and Diagnosis in the patient summary. This will also make it easy to see and select the diagnosis on the next visit, if it still applies.