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Line drawing for the Notes and the clinical record topic

Recording a diagnosis

Add a coded diagnosis to a client's problem list, date it, and mark it resolved.

Who this is for: Clinician, Associate clinician, Practice administrator

Record it

  1. Open the client. On Overview, find Problem list.
  2. Select + Diagnosis.
    The problem list with the diagnosis form open and an ICD-10-CM search typed.
  3. Under Diagnosis, search ICD-10-CM by what the condition is or by the code, and choose one.
  4. Optionally write it In the practice's own words. Left empty, the published wording is kept.
  5. If it was diagnosed before today, open It was diagnosed on an earlier day and give Diagnosed on. If you know when it began, open The condition started on a known day and give Onset.
  6. Select Add.

Note: Every code is recorded with its code system and release, and shown with them wherever it appears.

Mark it resolved

  1. Beside the diagnosis, select Resolve.
  2. Give Resolved on, or say why the day is not known.
  3. Select Mark it resolved. It moves to Resolved.

Last checked against Weft on 07 Oct 2026. Something on your screen reads differently? Tell us at support@weftary.com.