O-11-517 Update Diagnoses in Back Office

👤 RESPONSIBLE POSITION  |  ROLE

Clinical Supervisor

🎯 PURPOSE

Field clinicians are only able to update diagnosis codes in PointCare at specific time points including Start of Care, Recert, Resumption of Care, Follow Up and Add-On Evaluations. Back Office clinicians are able to adjust diagnosis codes in a Physician Order at any time as codes may require additions or revisions at other times during the Plan of Care. 

🔄 PROCESS

1. Go to Client Orders:

• From Clinical Input, go to Medical Record Info, then Orders:

• From Client Snapshot, select View All next to Orders:

2. Select Add Order:

3. Select Order Type: Physician Order. Then complete the rest of the applicable fields including Order Date, Time, and Verbal Order Date/Time

4. Select Content Reason: Diagnoses:

5. Within the Order Description, writer a brief narrative of the code revision/addition:

6. Select the Diagnoses tab:

7. The following edits may be made within the order:

1. Select Add Diagnosis to add a new diagnosis code:
2. To edit an existing diagnosis, select the diagnosis code and select Edit:
3. To delete a diagnosis, select the code and select Delete:
4. Select Move Up or Move Down to adjust the sequencing of codes:

8. With the Diagnosis editor, either type the code or select the magnifying glass to view the available diagnoses:

9. If selecting the magnifying glass, select All to ensure codes aren’t filtered out:

10. Select Save & Close:

11. Select Save & Close to close the order:

12. Select Yes:

13. Code adjustment and order description will print to the order:

📅 Effective: 09/18/2025  | 🛠️ Revised:  |  ✅ Approved: JS