As with most specialties, the diagnosis and assessment in dermatology generally translates to selection of applicable ICD codes. The unique design of the "Assessment/Diagnosis" block on our encounter form facilitates this workflow brilliantly. The block has two sections namely "Ongoing problems" and "New Problems". The helper window for ongoing problems presents that patient's master problem list whereas the helper window for new problems opens the list of provider's favorite ICD codes. He or she just needs to click on an ICD to move it over to the encounter form. The system comes pre-loaded with dermatology-specific ICD codes.

Note that the "Ongoing Problems" are only available in the helper window if the patient's master problem list on the History tab of the chart has problems entered on it OR if it is not the first encounter and proceeding encounters have "new assessments" entered on them. In other words, the new assessments of the previous encounters become the ongoing problems of the later ones. The physician starts with reviewing the "Ongoing Problems" and, if needed, selects the nodes that he/she re-evaluates or takes into consideration in context of the patient's current medical condition. In case the physician diagnoses a new problem, he/she just moves to "New Problems" section and selects the applicable code from the favorite list. Also note that any new problem is automatically added to the patient's master problem list on the History form.


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