How to Add a Diagnosis: DSM 5 Tab

Adding a Diagnosis: DSM 5 Tab

The DSM 5 tab is where you enter the client diagnosis.

1. With the client record open, click on Medical

2. Click on the DSM 5 tab

3. Click on the Add DSM 5 Entry button

4. Select the ICD10 code from the ICD10 drop-down.

• Note: once the ICD10 code is selected, the ICD9 code (legacy) will auto-populate.

5. Domain, Class and Disorder typically flow in order from one to the next with corresponding diagnostic information.

• Note: Once a Domain is selected, a Class is made available for selection (Class types available are restricted per the particular Domain chosen). Once a Class is selected, a Disorder is made available for selection (Disorder types available are restricted per the particular Class chosen).
• Note: Sub Class1 or Sub Class2 fields may also be selected where applicable. Criterion may be required for the chosen diagnosis (for example: Autism Spectrum Disorder). If it is, Criterion will be visible on the right side of the window and check boxes must be completed in order to save the information to the client’s record.

6. Check the Primary checkbox (if this is the primary diagnosis).

• Note: A primary diagnosis is required in order to create invoices in the system for services rendered. When checked, any invoices that are created will use this diagnosis (by default).

7. Enter the Date (required field). Note: does not affect billing.
8. Click on the Save button

Helpful Hint: the DSM 5 client diagnosis information can be formatted to the medical note template. That request is done via request to support.