How to Add a Coded Diagnosis

Quick Answer

Open the patient's record, navigate to the diagnosis or problem list field, type the first 3–4 letters of the condition, select the most specific SNOMED CT term from the suggestions, and save.

What Problem Does This Solve?

You need to record a diagnosis in a structured format so it feeds reporting, decision support, and the national health database. This guide shows the exact click path in SystmOne.

Before You Start

Prerequisites

• Access to the patient record you are documenting
• Write access to the clinical documentation node (Code Journal or Problem List)
• A confirmed or working diagnosis — avoid guessing when a precise term is required

Step-by-Step Instructions

1

Open the Patient Record

Navigate to the consultation or encounter you are documenting

1. From the CCMS Home Screen or Appointment Ledger, search for the patient.
2. Open the patient record and ensure you are in the correct consultation or encounter.

2

Select the Diagnosis Field

Click into the clinical coding area within the assessment or problem list

1. In the Clinical Tree, expand the relevant section:
   • Code Journal — for encounter-specific diagnoses
   • Problem List — for ongoing or chronic conditions
2. Click into the diagnosis / SNOMED CT input field.

3

Search for the Condition

Type the first few letters to trigger SystmOne's filtered suggestions

1. Type the first 3–4 letters of the condition name (e.g., diab for diabetes).
2. SystmOne displays a filtered list of matching SNOMED CT terms.

Search Tip

If the exact term does not appear, try a synonym or a broader term first, then narrow down from the suggestions.

4

Select the Most Specific Term

Avoid broad symptom codes when a precise diagnosis is known

1. Review the suggestion list and select the most specific term that matches your clinical findings.
2. Examples of specificity:
   • ✅ Type 2 diabetes mellitus (preferred)
   • ❌ Diabetes (too broad)
   • ❌ High blood sugar (symptom, not diagnosis)

Avoid Abbreviations Only

Do not rely on abbreviations like "T2DM" or "HTN" without selecting the full expanded SNOMED CT concept.

5

Add Free Text Context (If Needed)

Use the narrative field for atypical presentations or additional detail

1. If the presentation is complex, atypical, or requires explanation, click into the free text / narrative field.
2. Add concise clinical context — this supplements the code but does not replace it.

Keyboard Shortcut

Press the Tab key to quickly navigate between the code selection and free text fields.

6

Save the Entry

Confirm the code appears correctly in the record

1. Click Save or OK to confirm the entry.
2. Verify the coded diagnosis appears in the:
   • Problem List (for ongoing conditions)
   • Consultation summary (for encounter-specific diagnoses)

Result

The diagnosis is now stored as structured data, making it searchable, reportable, and visible across the care team.

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When to Use Free Text Only

Not every entry needs a code. Use this reference if you are unsure:

Situation	Action
Definitive diagnosis known	Always use SNOMED CT code
Rare or unlisted condition	Use free text + inform supervisor for code request
Symptom without confirmed diagnosis	Use symptom code; add free text for context
Administrative note	Free text only (not clinically coded)
Historical condition (resolved)	Use appropriate historical code or resolved status

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Troubleshooting

Cannot find the right SNOMED CT term

The condition does not appear in the suggestion list

Try these steps in order:

1. Search using synonyms or alternative spellings.
2. Try a broader term first, then narrow down from the suggestions.
3. If the term is genuinely missing, document in free text and inform your clinical supervisor.
4. Never invent or approximate codes — this compromises data integrity.

Read Code showing instead of SNOMED CT

Legacy record displays an old code format

Cause: Some older records display Read Codes instead of SNOMED CT.

Solution:

1. SystmOne maps Read Codes to SNOMED CT automatically in the background.
2. When updating legacy records, re-code using the current SNOMED CT term to ensure future compatibility.

Unsure whether to code a symptom or a diagnosis

Undifferentiated presentation with no confirmed diagnosis

Rule of thumb:

• If you have a confirmed diagnosis, code the diagnosis.
• If the presentation is undifferentiated, use the most specific symptom code available and add free text for context.
• Update the code later once a definitive diagnosis is established.