Clinical care

Record a diagnosis

Find a coded diagnosis, check its clinical and verification status, and submit it to the correct encounter.

Current source · Source reviewed; scoped synthetic Doctor diagnosis workflow observed · 3 min read

Before you begin

The patient has an open encounter at the facility, and that encounter is the patient's active encounter. Without an active encounter, the screen shows "Diagnosis cannot be recorded without an active encounter".
The encounter is not Completed, Cancelled, Discontinued, or Entered in Error. In these states, all add and edit controls are read-only.
You have the permissions listed below.

1. Open the diagnosis screen

Open the correct encounter. Open Encounter Actions, then Add Diagnosis, or use the d shortcut. If a Diagnoses section is present on Overview, its edit control opens the diagnosis form. Your facility may also provide a custom Diagnosis questionnaire through Forms. Confirm the patient and encounter before entering data.

Open Add Diagnosis from Encounter Actions. Actual MANSOQ software with explicitly synthetic local training data. — Open Add Diagnosis from Encounter Actions · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

2. Start a new diagnosis

Select Add Diagnosis. For each further diagnosis, the control reads Add another Diagnosis.

Start on the empty diagnosis questionnaire. Actual MANSOQ software with explicitly synthetic local training data. — Start on the empty diagnosis questionnaire · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

3. Search for the diagnosis

Open Add Diagnosis and type the diagnosis name or code. Choose a result from the configured system-condition-code value set. The audited default composition includes SNOMED CT clinical findings and ICD-10-AM; the terminology systems installed and configured on your instance determine the available results. Check both the code system and code when similar display names appear. Pinning controls may be available for preferred terms; use the search interface shown on your instance.

Search the installed I10 diagnosis term. Actual MANSOQ software with explicitly synthetic local training data. — Search the installed I10 diagnosis term · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

4. Select the term

Select a term. A new row appears with these default values:

Component	Default
Status	Active
Verification	Confirmed
Severity	Moderate
Onset Date	Today

The row shows a badge with the label Diagnosis. This badge marks the record as specific to this visit.

Review selected diagnosis defaults. Actual MANSOQ software with explicitly synthetic local training data. — Review selected diagnosis defaults · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

5. Change the values

Change the values of the row if you need to.

Component	What it captures
Status	The current state of the diagnosis: Active, Recurrence, Relapse, Inactive, Remission, or Resolved. The placeholder reads "Select diagnosis status".
Verification	The certainty of the diagnosis: Unconfirmed, Provisional, Differential, Confirmed, or Refuted. The placeholder reads "Select verification status".
Severity	The severity of the diagnosis: Mild, Moderate, or Severe. You can leave this field empty. The field then shows "Choose severity".
Onset Date	The date when the diagnosis started. MANSOQ does not accept a future date.

Note: MANSOQ does not offer Entered in Error as a verification value for a new diagnosis.

In the verified desktop calendar, dates after today are disabled. After the diagnosis is saved, its onset control is disabled in this edit path; do not assume the questionnaire permits changing a persisted onset date.

Choose clinical status. Actual MANSOQ software with explicitly synthetic local training data. — Choose clinical status · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Choose severity. Actual MANSOQ software with explicitly synthetic local training data. — Choose severity · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Choose diagnostic verification. Actual MANSOQ software with explicitly synthetic local training data. — Choose diagnostic verification · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Future onset dates are disabled. Actual MANSOQ software with explicitly synthetic local training data. — Future onset dates are disabled · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care. Future-date prevention is a disabled calendar control, not a failed server submission.

6. Add a note

To add a note, open the more-options (⋮) menu of the row. Select Add notes. Type the note.

Select Show notes to open the note text. Select Hide notes to close the note text.

After saving, the Overview Has Note → See Note action expands the persisted note beneath its diagnosis; Hide note collapses it.

Open Add notes from the row menu. Actual MANSOQ software with explicitly synthetic local training data. — Open Add notes from the row menu · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Enter a diagnosis-specific note. Actual MANSOQ software with explicitly synthetic local training data. — Enter a diagnosis-specific note · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

7. Add the other diagnoses

Repeat from step 2 for each further diagnosis.

If you select a term that the encounter already has, MANSOQ shows the warning "Diagnosis already exists!". MANSOQ does not add a second row.

This warning compares the selected code/system against the current form. It does not establish patient-record identity deduplication or prohibit the condition on a later encounter.

Duplicate condition warning retains one row. Actual MANSOQ software with explicitly synthetic local training data. — Duplicate condition warning retains one row · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care. Warning applies to the same coded condition in the current form; it is not proof of global patient deduplication.

8. Submit the diagnoses

Select Submit. Confirm the diagnosis on Overview, including status, severity, verification and onset. If a note was saved, use Has Note → See Note to inspect it. Reopening the questionnaire should retain the saved values; the persisted onset control is disabled in this path.

Submit the reviewed diagnosis. Actual MANSOQ software with explicitly synthetic local training data. — Submit the reviewed diagnosis · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Saved diagnosis and expanded note on Overview. Actual MANSOQ software with explicitly synthetic local training data. — Saved diagnosis and expanded note on Overview · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Permissions

Permission	Access
Can view clinical data about patients	Lets you open the clinical data of the encounter.
Can Read encounter related clinical data	Lets you see the diagnoses of the encounter.
Update Encounter related clinical data	Lets you record a diagnosis.

Doctors, nurses, administrators, and facility administrators have the Update Encounter related clinical data permission by default.

Without view access, the encounter shows "You do not have permission to view clinical data for this encounter".

Expected Outcome

MANSOQ shows the confirmation "Questionnaire submitted successfully".
The diagnoses appear in the Diagnoses section of the encounter Overview tab.
The diagnoses appear in the Past Diagnoses clinical history of the patient.

When the encounter has no diagnosis, the section shows "No Diagnoses" with the message "No Diagnoses have been recorded".

Version and facility configuration

This procedure is grounded in the repository’s version 3.1 user guide and the audited source revision. Available encounter types, required demographics, terminology, permissions and enabled services depend on your facility configuration. Use the labels and access controls on your own instance; the source references below identify the documented implementation.

Verified synthetic training example

The production-build walkthrough used Doctor on an active synthetic Inpatient encounter: search I10, select HYPERTENSION, inspect default Active / Moderate / Confirmed, observe future dates disabled, add a TRAINING ONLY note, trigger the duplicate warning, submit and reopen the saved row. Independent readback confirms one same-encounter I10 condition, Doctor author and the stored note. An earlier Observation encounter also contains its own independently verified I10 condition; this does not create a global duplicate patient.

Reopened diagnosis retains the saved values. Actual MANSOQ software with explicitly synthetic local training data. — Reopened diagnosis retains the saved values · 2026-10-18. Audited production build, explicitly synthetic active Inpatient encounter in the local Polyclinic. No clinical diagnosis, treatment or real patient care.

Saved onset and correction scope

The source disables onset editing once the diagnosis has a persisted ID. Other supported status/note corrections must follow facility policy. The screenshot verifies retained values and disabled onset; it does not establish every correction or entered-in-error path.

Troubleshooting

Diagnosis search fails or a required term is missing

Ask the terminology administrator to verify that the configured code system and release are installed and the condition value set can expand and validate the term. A public ICD-10-AM fragment is not a complete licensed release. Do not substitute an unrelated code to save the form.

A future onset date cannot be chosen

The calendar disables future dates in this path. Confirm the actual onset and current facility/local date; do not change the system clock to bypass the restriction.

Diagnosis already exists!

Check the existing row and update it as appropriate. The duplicate selector does not add another same-code row to the current form.

The saved onset cannot be changed

The audited form disables onset editing for persisted diagnosis IDs. Use the facility-approved correction process rather than creating a misleading second row.

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.