PCC PDF: https://www29.pointclickcare.com/help/online/en/SNF/en/documenting-medical-diagnoses.html

Medical Diagnoses

You can add a medical diagnosis for a resident in their Med Diag tab. You can also add medical diagnoses from other areas of the resident's chart:

  • Through section I of the MDS.
  • When entering an order.
  • From the Active Diagnoses pane of the resident's dashboard.

Note

The medical diagnoses use the International Classification of Diseases (ICD) library.

The Diagnosis Clinical Category appears in the Diagnosis listing in preparation for the Patient Driven Payment Model (PDPM), effective October 1, 2019, if enabled. For more information, see Completing Diagnosis Configuration

Procedure

  1. Clinical > Resident > Med Diag. 
  2. Click New Diagnosis.

  1. Complete the fields as required.
  2. Click Save.

Options

Below is a list of the options available to you.

  • Code - Type information or click the search icon. The Diagnosis Clinical Category appears, if enabled.
  • Description - Type information or click the search icon.

Date - Date autopopulates with today's date. Click the calendar icon to change or click Use admission date.

Rank - Select option. Designates the order the medical diagnoses appear on the Medical Diagnosis list.

Classification - Select option. Allows you to track the medical diagnoses based on the origin of the onset.

Admitting Dx - The primary diagnosis that can also be the Principal Diagnosis and Admission Diagnosis on the UB-04.

Admission - An active diagnosis at the time of admission.

Discharge - A diagnosis at the time of a discharge or the reason for the discharge.

During Stay - A diagnosis during the resident's stay.

History - A diagnosis previous to admission.

Comments - Type information, if applicable.

Confidential - Select option. Select to hide the diagnosis from certain reports. For example, the Admission Record and the Transfer/Discharge Record.

Therapy - Select if the diagnosis is a therapy diagnosis.

Hints and tips

For hard to find diagnoses, see ICD10Data.com.

Medical Diagnosis Ranking & Classification should be complete by MDS.

  • You can also Update OR Strikeout Medical Diagnosis by selecting on the update link 

 

Autopopulation of MDS 3.0 Items I8000A-J with Active Diagnoses

Effective October 1, 2019, the ICD-10 code for the primary diagnosis will autopopulate to a new MDS item, 

I0020B, per CMS guidelines. In preparation for a RUG-IV crosswalk to Patient Driven Payment Model 

(PDPM) prior to October 1, 2019, PointClickCare now autopopulates the primary diagnosis to I8000A of the MDS. The resident's active primary diagnosis from the Med Diag tab autopopulates to item I8000A even if the diagnosis is already selected in items I0100 to I6500.

Additionally, the primary diagnosis in the Med Diag tab now shows in bold for easy identification. These enhancements apply to all MDS 3.0 records, and includes Swing Bed facilities.

If there are multiple diagnoses ranked as primary, item I8000A is autopopulated with the diagnosis with the most recent Date. If the Date is the same, autopopulation is by lowest to highest ICD-10 code number.