SANDI - Clinical Diagnosis

View/Add Clinical Dx

From the SANDI Patient Dashboard, select the arrow beside ClinicalDx.

Notes:

• By default, all previous diagnoses will be listed. You may select a specific visit in the Visit box. 
• The Date references the visit discharge date if it exists. If the visit has not been discharged, it will show the visit date.

Actions Buttons Overview

- Edit Clinical Dx

- Delete Clinical Dx (In Draft Only)

- Verify/Finalize (PIN) a diagnosis

- Add a Recheck

- Retract a diagnosis (Only Medical Records can Retract)

Add a Clinical Dx

Select the Add Clinical Dx button and the Create Patient Dx screen will appear.

Overview of the Create Patient Dx Fields 

1. Dx: is the description of the clinical diagnosis. Begin typing to see a list of over 2000 available diagnoses.
2. Visit: This is the visit that the Dx is being applied to. A diagnosis must be associated with a visit. 
3. Diagnosing Clinician: is the clinician that is making the diagnosis.
4. Type:is where the diagnosis is identified as one of the following:
   • C: Confirmed (most used)
   • S: Suspect
5. Recheck: Check this box to identify the diagnosis as a recheck verses a new finding.

A disorder or finding IS considered a recheck when:

• That disorder or finding was present on a previous visit and is to be considered the same episode of disease as in the previous visit. This is checked so that the diagnosis is not counted multiple times, usually for research purposes when doing queries. 

A disorder IS NOT considered a recheck when:

• That disorder reoccurs independently of a previous episode of the disease. For example a recurrence of Otits/Ear Infection that happened a few months ago, healed and it present again today would NOT be a recheck but rather a new occurrence.

Note: Do not confuse the fact that the animal is coming to the hospital for a “recheck” appointment type with the rechecking of a course of disease or post-operative outcome of the patient.

Edit, Verify or Retract Diagnoses

After entering the diagnoses on the visit, you may edit, verify(finalize) or Retract entries via the Actions buttons.

Editing a Diagnosis

Note:  All fields except Visit may be edited by selecting the Edit Icon.  

Make your changes and select Submit.

Deleting a Diagnosis

1. To delete a diagnosis, select the Delete Icon .
2. Select Submit to permanently delete the Dx.

Verify/Finalize (PIN) a Diagnosis

Please note that all diagnoses must be verified (pinned) by a clinician.

1. To verify/finalize (PIN) a diagnosis select the Verify icon

2. Enter your PIN and select Verify.

3. The status will change from Draft to Final after entering your pin and selecting verify.

Verify/Finalize (PIN) ALL a Diagnoses

1. To verify/finalize (PIN) all diagnoses select the Verify All button 

2. Enter your PIN and select Verify.

3. The status will change from Draft to Final after entering your pin and selecting verify.

Retract a Diagnosis

Only medical Records can retract a diagnosis. Email them at medrec@vetmed.illinois.edu if you need assistance. 

Request New Clinical Dx

1. Select the Request New Clinical Dx button and the Request New Clinical Dx screen will appear.

2. Type the clinical diagnosis you would like added to SANDI amd be sure to be detailed in your request.

3. Select Submit when finished and your request will be set to Medical Records.  Below is a sample of what will be sent.