Use the Problems module to record an encounter's diagnosis using the ICPC list. ICPC is an International Classification method for Primary Care encounters.
To add a problem from the ICPC list:
- Start an encounter with the patient.
For a detailed explanation of how to do this, see the Start an encounter article.
When the encounter starts, the Current Encounter section will open and display the clinical modules.
- Select Problems from the Current Encounter menu.
The Define Problem/REF screen will open (screenshot below).
- In the Problems section, select Predictive Search (ICPS and Common) or ICPC Search.
- For Predictive Search, enter the problem's name in the Filter Current List field to display the problems to choose from.
- For ICPC Search, use the Keyword, Code and Chapter fields provided to display the problems to choose from.
- Select the problem.
- As an optional step, you can use the Extra Text field to add a note, for example, "left side" or "Head".
- Select the Select Problem button (You can also double-click the problem).
This adds the problem to the tab above RFE that previously said Undefined.
To add additional problems, select the blue + icon on the top left and repeat the steps above.
- Add to History adds the problem to the patient's history.
- Add to Common adds the problem to the practice's Common Problems list.
- Onset Date records when the problem started.
This is required for My Health Record Shared Health Summary uploads.
- Accurate To notes the approximation of the onset date.
- Criticality can be used to sort a patient's problems in Summary Views.
- Select Close to save the problem.
When you select refresh, the problem will appear in the patient's Summary Views > Problems tab.