Diagnoses
A patient's diagnoses, recorded from an encounter or directly — with how sure it is, its status, and no codes to learn.
The Encounters tab on a patient's record shows the patient's encounters at the top and their Diagnoses underneath.
Two ways a diagnosis gets there
- From an encounter. When you record your decision you can save conditions as diagnoses. They are marked from an encounter, with a link back to it.
- Recorded directly. Select Record a diagnosis on the tab. This is for history — a condition the patient already has, or something they were told elsewhere. No safety check or encounter is needed, and these are marked recorded directly.
What a diagnosis holds
| Field | What it is |
|---|---|
| Condition | A plain name. Pick a common one from the list (so the same condition is always spelled the same way) or type your own. |
| How sure is it? | Confirmed — established by a clinician or by testing. Possible condition — suspected, not confirmed. Clinical consideration — something to keep in mind or rule out. |
| Status | Active, Resolved or In remission. Change it any time from the list on the row. |
| Since | When it started, if known. Optional; can't be in the future. |
| Notes | For example "Told by another doctor". |
A diagnosis that came from a suggested condition also shows its confidence label (High, Moderate or Low) and, in the encounter, the findings that supported it.
There are no codes to look up or remember. A symptom on its own isn't a diagnosis — symptoms stay in the encounter's record of what the patient presented with.
Changing and deleting
You need Edit on the Diagnosis permission line to change a status, and Delete to delete one. A deleted diagnosis goes to the Recycle Bin and can be restored from there.
How this differs from the Conditions tab
The Conditions tab is a short list of the patient's known long-term conditions, edited from the patient form. Diagnoses are a fuller clinical record with confidence and status, and can come from an encounter. Both exist, and neither changes the other.
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