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Kareo Help Center

Add a Problem

With Kareo Clinical, you can add current problems and conditions for patients, as well as past medical history. When adding a problem or condition, you can also enter an associated diagnosis. If the patient does not have any problems, mark the "No known problems" box.

 

Navigate to Patient Chart / Problems

  1. Enter the first 2–3 letters of the patient's name in the top search box.
  2. Click to select the patient from the auto-populated results. The patient's chart / Face Sheet  opens.
  3. Click Problems in the left menu. The Problems List  displays.
 

Add Problem to Patient's Chart

  1. Click +Problem on the right side of the page. The Add to Problem List  window opens.
  2. Enter the Problem/Issue details and click Save & Close or Save & Add Another.
    1. Problem/Issue: Start typing the problem; a list will appear from which to choose. You can type in a problem that is not in the list, however, Kareo Clinical recommends selecting from the list when possible, as the information is codified and will help with reporting and clinical decision support in the future.
    2. ICD-9: The diagnosis description or ICD code will auto-populate after the problem/issue is entered. If you prefer, you can type the diagnosis code before the problem; once you enter the code, a list of problems will appear for you to easily select and enter in the Problem/Issue field. The ICD can be changed. Click Browse to search codes. Entering a diagnosis is recommended but not required.
    3. ICD-10: Enables you to view code mapping between ICD-9 and ICD-10, and dual-code a problem. Click Browse to search for codes, switch between ICD-9 and ICD-10, and select the applicable code.
    4. Type: Select if the problem is Acute or Chronic.
    5. Start Date: Enter a date when the problem began, if known.
    6. Comments: Optional. Enter any notes.
 

ICD Browser

  1. Favorites: Provides a list of the codes you frequently use.
  2. Patient Dxs: Displays the patient's previous diagnosis.
  3. 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.
  4. Enter a word or code and click Search.
  5. Switch between ICD-9 and ICD-19 codes, or click 9 -> 10 to view code conversion.
  6. Hover over a code and click the star to add to favorites.
 

Tips

Use these examples to help you choose the appropriate options as you record the patient's problems:

  • An old, resolved condition that you want to add to medical history but not to the active Problems List (for example, the patient had thyroid cancer and has since had all of the thyroid removed): Choose Inactive and Resolved. In this case, the condition is recorded in the inactive Problems List and in Past Medical History.
  • An old condition that is ongoing for which you want to capture historical data and also add to the active Problems List (for example, the patient was diagnosed with hypertension 20 years ago and is still being treated for it): Choose Active and Chronic. In this case, the condition is recorded in the active Problems List, Past Medical History and in the currently opened encounter note (if you are adding the problem to an encounter note).
  • A new condition that needs to be captured as both an active problem and in the Past Medical History (for example, the patient is being seen for newly diagnosed diabetes): Choose Active and Chronic. In this case, the condition is recorded in the active Problems List, Past Medical History, and in the currently opened encounter note (if you are adding the problem to an encounter note.
  • A new condition needs to be captured within the current encounter but not in the Past Medical History (for example, a patient has a cold or the flu): Choose Active and Acute. In this case, the condition is recorded in the active Problems List and in the currently opened encounter note (if you are adding the problem to an encounter note).
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