Once the Diagnoses have been selected and entered, for each line item, there are options available.
•Modifier – enables the selection of Mild, Moderate, Severe, Acute, or Chronic. It may also be left blank.
•Onset Date – when there are multiple diagnoses for the patient, if each started at a different time, there is the option to enter this information on this window. Note that by using the Setting described earlier in this chapter, the user has the ability to display this information only on this screen or to have it display in the generated SOAP note.
•Status – as long as the patient is being treated for that line item, the status should be set to Active. When the patient is no longer being treated for a specific diagnosis line item, the status should be changed from Active to either Resolved or Inactive. Any time a new Diagnosis Set is created for the patient, the old Diagnosis Set should have its line items set to Resolved or Inactive. Note that this Status item is a Medicare Meaningful Use requirement.