# Entering Diagnosis Codes for Specific Orders (CIDC Overview)

Note: Providers will not see most CIDC changes in CPRS until the site enables a system-level switch and IRM or CAC staff enables a user-level switch (parameter) for specific providers. Some changes for co-pay on service connection will be available as soon as patches from other packages are installed.

With Clinical Indicators Data Capture (CIDC), clinicians who hold the Provider key and the ORES key must enter at least one diagnosis, required service connection, and the appropriate treatment factors for specific types of orders, while clinicians who hold the Provider key and the ORELSE key will be prompted for the same information but not required to enter it before signature. CPRS will prompt for CIDC information for the following types of orders:

· Laboratory (outpatient only)

· Outpatient Pharmacy (outpatient only)

· Radiology (inpatient and outpatient)

· Prosthetic Consults (inpatient and outpatient)

Clinicians can enter up to four diagnoses for each order and designate one of these as the primary diagnosis.

Clin icians should use their best judgment to enter diagnoses that might be symptomatic when ordering tests rather than the resulting diagnosis after a test. They are not entering the suspected diagnosis, but the actual reason the patient was sent for the lab t est or radiology procedure. For example, if a clinician sees a patient wi th a high fever and difficulty breathing, the clinician may believe that the patient has pneumonia, but if the clinician orders tests to verify the pneumonia, the clinician would ente r a diagnosis of "fever", not "pneumonia".

When Will Providers See CIDC Changes?

For clinicians to use the new features to enter at least one diagnosis for these orders, the following four conditions must be met:

· The site must install the appropriate patches.

· The clinician must have the Provider key and the ORES key (CIDC entry required) or the ORELSE key (CIDC entry optional).

· The site must enable the master Clinical Indicators Data Capture switch.

· The individual Clinical Indicators Data Capture switch enabled for the clinician.

Instructions for enabling Clinical Indicators Data Capture at both the site and individual level are available in the CPRS Technical Manual: GUI Version.

Where Will Users See the Changes?

When the site enables C IDC at the site level and for individual clinicians, the clinicians who hold the Provider key will see the following changes in CPRS:

· The Review / Sign Changes and Sign Selected dialogs will now have areas where diagnoses will be captured for the specified orders. These diagnoses and treatment factors will then be available on the Encounter form if the clinician signs the orders first.

· The Encounter Form's Diagnosis tab will enable clinicians to enter diagnoses for the encounter. These diagnoses will then be available on the orders tab if the clinician does the encounter form first.

· Order detailed displays will now display the associated treatment factors and diagnoses.

· A new Assign Diagnosis to Order(s) dialog has been added for clinicians to use in designating one or more diagnoses for each of the types listed above.

· A new Personal Diagnosis List dialog to create a personal diagnosis list that providers can use as a source on the new Assign Diagnosis to Order(s) dialog.

What Features in CPRS Make Entering Diagnoses Easier?

CPRS has the following features to help clinicians assign diagnoses to orders:

· Automatically copying the diagnoses, service-connection, and treatment factors when a user copies, renews, or changes an order.

· Selecting a group of orders to assign diagnoses at the same time. Clinicians can select a group of orders using the Windows conventions of Shift + Click to highlight a contiguous group of orders and Crtl + Click to add individual orders to the group. All of the orders can then be assigned the same primary and secondary diagnoses.

· Copying and pasting diagnoses from one order to others. Clinicians who hold the Provider key can highlight an order on the signature dialogs, copy the diagnosis, highlight one or more additional orders, and paste the same diagnosis for them.

· Providing multiple sources for diagnoses. CPRS displays multiple diagnoses sources for clinicians to locate the appropriate diagnoses:

o Orders written today if on the Encounter form

o Encounter diagnoses from today if writing orders

o Personal Diagnosis List

o National Encounter forms if defined

o Problem List entries

o The Lexicon search.

· Automatically populating treatment factors for diagnoses selected from the Problem List. One possible source for diagnoses is the patient's Problem List entries. If a problem has service connection and treatment factor information associated with it on the Problem List and the user selects that Problem List entry as the diagnosis, CPRS automatically places checks in the appropriate check boxes on the signature forms. The provider can, of course, edit the checks.

· Creating a personal diagnosis list. Developers provided personal diagnosis list that is specific to each clinician. Each clinician can quickly add diagnoses that he or she frequently uses so that they can be assigned quickly.

Related topics

Review / Sign Changes Dialog

Sign Selected Orders Command