Diagnosis

1. Diagnosis Entering and Updating a Diagnosis

2. Diagnosis Form: Purpose • The Diagnosis form can capture diagnosis information across all five Axes. • The information is both consumer and program specific. However, information from one program can be defaulted into another when appropriate. • In addition to the Axis, the form records the Principal Diagnosis. The principal diagnosis is the basis for billing for all programs except the Article 16 clinic which bills based on a medical diagnosis specific to the treatment.

3. Step 1: Select the Diagnosis form

4. Step 2: Select the consumer

5. Step 3: Select the program

6. Entering a new diagnosis – pg 1 1. Click Admission and the date of admission for the selected program will auto-populate. 2. Use 9:00 AM as standard in the Time of Diagnosis field. 3. You must enter an Axis I diagnosis but all other Axes are optional. However staff is expected to enter Axis III (medical diagnosis) information.

7. Additional guidance Autism Although developmental disabilities are generally captured under Axis II, i.e. 317 (Mild Mental Retardation), that is not always the case. Individuals with autism may be considered developmentally disabled, but autism is an Axis I diagnosis, i.e. 299.00 (Autistic Disorder) or 299.80 (Asperger’s Disorder).In this case a consumer in a developmental disability service would have a Principal Diagnosis that is an Axis I. No Axis I Diagnosis Since Axis I is a required field you must enter something in this field. If the consumer does not have an Axis I diagnosis, enter “No diagnosis” in the field and select the result, i.e. V71.09.

8. Entering a new diagnosis – pg 2 Select the Principal Diagnosis. The drop down dictionary will show all diagnoses entered for the consumer. The principal diagnosis must match the program; select Axis I for mental health services and Axis II for developmental disability services.

9. Entering a new diagnosis – pg 3 Enter the Diagnosing Practitioner. Select the specific practitioner if known. If not known enter XXX and select “SEEFILEXXX” from the drop down dictionary. Then submit form.

10. Using the default feature If the consumer already has diagnosis information set up against a program, the information can be defaulted into the Diagnosis form for another program. If this action is indicated, open the diagnosis form for the new program and in the top two drop down selections indicate the episode from which the information will be copied and the specific principal diagnosis to be defaulted.

11. Completing the default When you click Yes in the pop-up, the diagnosis information will automatically populate all the fields, except for Date and Time of Admission. Click Admission to populate the date field and enter 9:00 AM in the time field, then submit.

12. Editing an existing diagnosis Select Edit – not Add. Make all necessary changes and submit.

13. Updating diagnosis Click Add and open the form. Then default the existing information, make changes and - most importantly - change the Type of Diagnosis to Update and enter date and time.

14. Never ever … Create more than one Admission diagnosis for a program. If you need to change something, use Edit. If you need to update a diagnosis you must ensure that you add it as an Update – not as Admission. If in doubt – ask your supervisor or call the HelpDesk for assistance. Thank you.