Episode Diagnosis

In VetView 5.0, the Diagnosis record group remains its own “smart object” in the medical record. However, it has become more tightly integrated with Documents and Problems, so that a Diagnosis can also be added as a Problem and SOAPed, or a Diagnosis can be added directly through a Document as appropriate.

Diagnosis in 5.0 are also better supported via Hospital and Lab requests. The attending clinical staff can review the diagnosis submitted by Request units, and elect to include them in the patient’s episode Diagnosis as appropriate.

Diagnosis Record Group

If your Episode Type wasn’t set to have a Diagnosis group preloaded, you can manually added a Diagnosis by right clicking on the Header, and choosing Add New Element → Diagnosis.

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Add Diagnosis via Right Click Menu or Hamburger Menu

If the Episode Type is set to display or require it, the Diagnosis Record group will already be available on the Patient Record.

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Empty Diagnosis Record Group

Add Diagnosis Button

On the Diagnosis header, click on the Add Diagnosis button to load the Diagnosis Coding window.

You can also choose Add Diagnosis from the hamburger menu on the Diagnosis record group header.

Add Diagnosis Window

The Diagnosis Coding window itself is similar to earlier versions of VetView. Search for the code by keyword, or sort through the codes your hospital has loaded by Coding Subset, Anatomical Site, etc.

Once you have identified the code that you want to add, select the code from the list. Add any additional attributes to the code at this point.

Add to MPL

Turn this flag on to move the Diagnosis over to the patient’s Master Problem List. It will appear on the list with the source of “Diagnosis.”

Primary

Turn this flag on to indicate that this is the primary diagnosis for the patient for the current episode.

Add Comments

You can add additional comments about the Diagnosis if you feel that it will be important for future case reviews, or for future clinicians to review.

Diagnosis Results: Presumptive or Definitive

Select between these two options to indicate whether this is still a working assumption for the patient, or if the diagnosis has been confirmed through lab testing or imaging or other means. If the diagnosis is generally one determined by a positive lab test, you can have it default to definitive.

Other Attributes

SNOMED code attributes can automatically pull in depending on how the code was set up in your system. In the example above, Urinary Tract Infection automatically pulls in the anatomical site, the body system, and the etiology.

Approve Diagnosis

Diagnosis in VetView 5.0 can be approved in the same manner as Documents. Click on the check mark on the Diagnosis row to approve individual diagnosis, or you can approve them all at once at the same time as Document approval.

Diagnosis in the Document Approval Window

In VetView 5.0 the Diagnosis approval is identical to the Document/Request approvals and they are handled in the same window.

Request Diagnosis

Diagnosis can be submitted by clinicians outside of the attending unit. These Diagnosis appear in the Diagnosis group and can be reviewed by the attending clinical team and either promoted to an Episode diagnosis, or left as a Request diagnosis.

This gives the clinical team the opportunity to choose what diagnosis to promote to the Master Problem List for the patient.

Review Request Diagnosis

The Request Diagnosis appear in the main Diagnosis section. The attending clinical staff can review them and choose to add the Request Diagnosis as an Episode Diagnosis, or Delete the diagnosis instead.

Accept Request Diagnosis

If you choose to accept the diagnosis as an Episode Diagnosis, you will have all the options for any other episode Diagnosis, including the chance to Add to MPL and indicate it is a Primary diagnosis.

Print Diagnosis

If you print the Diagnosis, only Episode Diagnosis will appear. Request Diagnosis that were not approved by the clinical staff will not appear on the printed report.