Registering Additional Diagnoses
The diagnosis field is a mandatory field in OPIS that must be completed prior to placing orders and generating NDFP forms.
Follow these steps to enter additional diagnoses:
1. From the main OPIS menu bar select Diagnosis & Staging and diagnosis History.
The diagnosis history tab will open up. It may be blank if you have not searched for a patient in OPIS since you logged in.
2. Type the patient’s medical record number (MRN) in the Chart field and press Enter on your keyboard.
3. The diagnosis history tab will display the patient’s diagnosis history. Click the Add a new disease button located on the bottom left of the screen.
4. Notice the Disease No. field updates to the next available number. Click the LOV (List of Values) button beside the Admit ICD Code field to search for a diagnosis.
Note: The required fields are labeled with bold text. The Disease No. will automatically fill in with the next available sequenced number and the Registration Date will default to today’s date. The only field that needs to be filled in is the Admit ICD Code.
The ICD site search window will appear.
5. Enter your search criteria and click Find to display your search results.
Note: In the above example, we searched for description 'breast' and ICD revision '10'.
6. Select the diagnosis description and click OK.
7. Click the Save icon located on the OPIS toolbar to save your changes.
