Use the Problems module to record an encounter's diagnosis using the Free Text field. The Free Text option is useful for clinics without access to ICPC.
Alternatively, you can record a problem by selecting it from the existing or recent problems list or selecting one from the ICPC list. The method used is determined by the doctor or the practice's guidelines.
To add a problem using Free Text:
- Start an encounter with the patient.
For a detailed explanation of how to do this, see the Start an encounter article.
When the encounter starts, the Current Encounter section will open and display the clinical modules. - Select Problems from the Current Encounter menu.
The Define Problem/REF screen will open (screenshot below). - In the Problems section, select Free Text.
- In the Problem field, type in the problem's name.
- As an optional step, you can use the Extra Text field to add a note, for example, "left side" or "Head".
- Select the Select Problem button.
This adds the problem to the tab above RFE that previously said Undefined.
To add additional problems, select the blue + icon on the top left and repeat the steps above.
Optional selections:- Add to History adds the problem to the patient's history.
- Add to Common adds the problem to the practice's Common Problems list.
- Onset Date records when the problem started.
This is required for My Health Record Shared Health Summary uploads. - Accurate To notes the approximation of the onset date.
- Criticality can be used to sort a patient's problems in Summary Views.
- Select Close to save the problem.
When you select refresh, the problem will appear in the patient's Summary Views > Problems tab.
The Define Problem/REF screen will open (screenshot below).