Add a Problem in a Note
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With Kareo Clinical, you can add a patient's current and previously documented problems in the Assessment section of a note. When a problem is added, it also displays in the Plan section to allow for writing a plan specific to each problem identified for the patient.
Open a Note
- Enter the first 2–3 letters of the patient's name in the top navigation bar search box.
- Click to select the patient from the auto-populated results. The patient's record opens to the Face Sheet.
- Click Notes in the left menu. The Notes page opens.
- Click Open on the right of an existing note or click Create Note to open a new one.
Open Problems in a Note
- Click Assessment. The Assessment box opens.
- Click Include Problems. The Include Problems window opens to the Active problems in the patient's record.
Include Existing Problems in a Note
Active and Inactive problems in the patient's record can be added to a note.
- By default, the Include Problems window opens to display a list of Active Problems from the patient's record. Click Inactive to view the patient's problems marked as Inactive.
- Check the box next each problem you want to include in the note.
- Click Include. The Include Problems window closes and the selected problem(s) display in the Assessment box.
- Click Save & Close when finished.
Add a New Patient Problem in a Note
Current problems and conditions for a patient can be added in a note. When a new problem is added to a note, it is also added to the Problems list in the patient's record.
- Click +Problem in the upper right of the Include Problems window. The Add to Problem List window opens.
- By default, the new problem is set to display as Active. Click Inactive to add the problem to the Inactive list.
- Add the problems one of three ways:
- ICD-10 Problem (Recommended): Search your saved favorite codes or enter general diagnosis keyword(s) or a code to search for a specific code.
- ICD Browser: Search for a specific code, switch between ICD-9 and ICD-10, choose from your saved coding favorites, or select a previous Dx code from the patient's record.
- Problem/Issue: Search for a problem by entering clinical (SNOMED) terminology.
- Click to select if the problem Type is Acute or Chronic. will auto-set to Acute or Chronic based on the problem that is entered. Click to change the Type, if desired.
- Enter the problem Start Date and End Date (for Acute problems), if known.
- Enter any optional notes about the problem in the Comments box.
- Click Save to add the problem to the patient record.
Add a Problem Using the ICD-10 Problem Field
It's best practice to use the ICD-10 Problem field as a starting point when adding a problem.
- Click in the ICD-10 Problem field to view and select from a list of saved coding favorites.
Note: Favorite ICD-9 codes are also available and will map to ICD-10 if selected.
- Search for a code by typing the diagnosis description or code in the ICD-10 Problem field and selecting from the list of results. When More > displays, click to open more defined results and find the most accurate code.
- Once an ICD-10 code is entered, the appropriate problem auto-populates in the Problem/Issue field, or a list displays if more than one option is available.
- The system auto-populates the appropriate ICD-9 code (if available) after an ICD-10 code is entered.
Note: The ICD-9 field is optional and can be left blank.
Add a Problem Using the ICD Browser
The ICD Browser window allows you to search for a specific code, add a code to your favorites, switch between ICD-9 and ICD-10, choose a code from your saved favorites, or select a previous diagnosis code from the patient's record.
- Click Browse in the Add Problem to List window. The ICD Browser window opens.
- Favorites: Provides the list of the codes you have saved as favorites.
- Patient Dxs: Displays the patient's previous diagnosis.
- Search: Search by code or description. For example, enter a problem in the search field and click Search. Note that clicking x clears the entry for a new search.
- Enter a word or code and click Search.
- ICD-10 codes display by default. Click the drop-down to switch between ICD-9 and ICD-10 codes, or click 9 -> 10 to view code conversion.
Note: an ICD-10 code must be entered to add a new Problem.
- Click the triangle to refine results and find a more specific code.
- Click a code in the list to select it. The selected code displays highlighted in blue.
- Hover over a code and click the star to add it to your coding favorites.
- Click Done to add the selected code. The Add to Problem List window re-opens and the selected code displays.
Add a Problem by Searching Problem/Issue Keyword(s)
Add a problem to a note by searching for the clinical name or code of the problem/issue. This field provides more general search results and specifically targets clinical terminology and SNOMED codes.
- Begin entering the name of the problem/issue or code and select it from the results when displayed.
- Once a Problem/Issue is entered, the most appropriate ICD-10 codes display below the ICD-10 Problem box. Click to select the correct ICD-10 code.
- The system will auto-populate the appropriate ICD-9 code, if available.
Note: A problem not in the list can be manually entered, however, selecting from the list of results whenever possible is recommended. The results list is codified to help with reporting and clinical decision support.