How to Add Problems and Diagnoses

How to Add Problems and Diagnoses

Problems structure the consultation using the POMR approach. Each selected problem gets its own tab for documentation.

Adding Problems

In the Clinical Record step, search for and select problems from the SNOMED-coded problem list. You can:

• Select from the patient's existing active problems
• Search for new problems by name or SNOMED code
• Add multiple problems to a single consultation

Problem Tabs

Each selected problem appears as a tab at the top of the Clinical Record step. Click a tab to switch between problems. All Record section documentation (History, Examination, etc.) is associated with the currently active problem tab.

General Consultation Notes

If no problems are selected, a General Consultation Notes tab is shown instead. Use this for consultations that do not relate to a specific problem, such as administrative tasks or general check-ups.

Episode Types

Each problem requires an episode type that describes the nature of this encounter:

Episode Type	When to Use
New Episode	First presentation of this problem
Review	Routine follow-up of an existing problem
Flare Up	The condition has worsened or recurred
End Episode	The problem is resolved, care is concluded

Problem-Specific Notes

Each problem tab has its own notes area. Use this for notes specific to that problem, separate from the Record section documentation.

Switching Between Problems

Click the problem tabs to switch context. The Record and Action sections update to show data linked to the selected problem. This keeps documentation organised when addressing multiple issues in a single consultation.

Tip: For complex consultations covering several problems, document each problem thoroughly in its own tab. This creates a clear audit trail of what was discussed and decided for each condition.

Searching beyond clinical findings

The Problem picker also searches three additional SNOMED hierarchies so you can record more of the patient's story as a problem when that's clinically appropriate:

• Procedures — surgeries and procedures with ongoing care implications (amputations, joint replacements, splenectomies). Useful when the procedure itself is what you need to reason about in later consultations.
• Histories & risk — "History of myocardial infarction", "Family history of breast cancer", "At risk of falls", and similar context-bearing concepts.
• Social context — homelessness, lives alone, carer status, occupational risks, and other social factors that shape a patient's care plan.

After the SNOMED Search Results section, you'll see up to three extra grouped sections labelled with a coloured badge (Procedure, History, Social). Selecting any row stores it the same way as any other problem — you decide what belongs on the problem list.