Diagnosing a New Condition
Accurately documenting active conditions is essential for maintaining comprehensive patient records and ensuring proper clinical care. This article explains how to use the Diagnose and Add Condition commands in Canvas Medical to record conditions, prevent duplicate entries, and create structured clinical documentation.
User's Guide
Adding a New Diagnosis
The Diagnose command creates a clear and structured entry for new patient conditions in the chart.
To add a diagnosis:
Open the patient's chart
Add the Diagnose command to a new or existing note
Complete the command fields. The only required field is the diagnosis.
Diagnose: Search for the condition using free text or ICD-10 code
Background: Provide detailed history of the condition
Approximate Date of Onset: Indicate when the condition began (e.g., "yesterday," "last week," "3 years ago," "2015")
Today's Assessment: Summarize clinical reasoning by integrating subjective and objective data from the examination
Click Record to save the diagnosis. The condition will immediately appear in the patient summary as an active entry.
Preventing Duplicate Diagnoses
If the patient has already been diagnosed with a condition in Canvas, the system displays: "This patient has already been diagnosed with this condition" to prevent duplication.
Best Practice: Use the Assess Condition command to update existing diagnoses rather than creating duplicates.
Adding a Condition Without Assessing It
The Add Condition command records a coded (ICD-10) condition on the patient's Conditions list as active, without opening an assessment for it. Use it when a condition was diagnosed previously and is still active, such as one carried over from an outside record or an intake form, where there is nothing to assess at today's visit.
To add a previously diagnosed condition:
Open the patient's chart
Add the Add Condition command to a new or existing note. It is in the note's History section.
Complete the command fields. The only required field is the condition.
Condition: Search for the condition using free text or ICD-10 code. This is the same picker the Diagnose command uses.
Background: Provide history of the condition
Approximate Date of Onset: Indicate when the condition began (e.g., "last week," "3 years ago," "2015")
Comments: Additional notes pertaining to the condition (up to 1000 characters)
Click Record to add the condition. It appears in the patient summary as an active entry.
Key points:
No assessment is opened for the condition, and the visit is not documented as having assessed it
If the condition is already on the patient's Conditions list, Canvas displays: "This condition is already on the patient's conditions list."
Once the condition has been assessed, the Add Condition command can no longer be entered in error, because doing so would remove the condition the assessment describes
Configuration & Set Up
No special configuration is required. The Diagnose and Add Condition commands are available by default in all patient charts.
FAQ & Troubleshooting
Q: Should I use Diagnose, Add Condition, or Past Medical History?
A: It depends on whether the condition is active now, and whether you are assessing it.
Diagnose: the condition is active and you are assessing it for the first time
Add Condition: the condition was diagnosed previously and is still active
Past Medical History: you are backfilling a condition the patient had in the past that is not active now
Q: How can I add a diagnosis/ICD-10 code that's not in the system?
A: Diagnosis codes cannot be added manually. Canvas updates ICD-10 codes in accordance with CMS on April 1 and October 1 every year.
Q: What if I enter the wrong diagnosis?
A: Use the Change Diagnosis command to update the condition while preserving historical data. If historical data is not needed, enter the diagnose command in error and enter new.
Related Resources
Keywords: diagnose command, add condition command, new diagnosis, ICD-10, clinical documentation, patient conditions, duplicate diagnosis, active conditions
Categories: Clinical Documentation, Condition Management