CalMHSA Learn (LMS System)
Live Chat Support
EHR Bulletin
Check/Update Existing Issues

MENU

How to Document a Diagnosis for a Client

Step by step video guide here:


To add a diagnosis, follow the steps below:

  1. You must first have the client open, click the Search icon.
  2. Type Diagnosis into the search bar.
  3. Click to select Diagnosis Document (Client).
  1. If the client already has an existing diagnosis document, the most recent diagnosis document will open. Click the New icon. 
    • Note: If this a new client and no diagnosis document exists then you will skip this step. 
  1. In the CDAG Program Enrollment window pop-up, click the drop down and click to select the appropriate program.
  2. Click OK to continue.
  1. The Diagnosis Document screen will open, click in the code field and enter the diagnosis code.
  2. A list of matching diagnoses will populate, click to select the appropriate diagnosis
    1. Alternatively, you can click in the Description filed and enter the diagnosis description.
    2. A list of matching diagnoses will populate, click to select the appropriate diagnosis
  1. You must document if the diagnosis is Primary, Additional, or Provisional. Click the drop-down menu in the Type field and select the appropriate option.
  1. If a severity level is appropriate, click the drop-down menu in the Severity field and select the appropriate option, mild, moderate, or severe.
  1. To document that the client is in remission, click the drop-down menu in the Remission field and select the appropriate option.
    1. If this diagnosis is informational only and not a billable diagnosis, click the No radio button in the Billable field.
  1. Click the Insert button to add the diagnosis. It will appear in the Diagnosis List grid below. Repeat steps 1-12 for remaining diagnoses.
  1. Click Sign to complete and generate the document.

Updated 10/15/24