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How to Document Clinical Notes Using Specialty Charts and ICD-10

This article explains how doctors document clinical information in Helix using specialty-specific medical charts, record general medical history, and assign ICD-10 diagnosis codes during a patient visit.

🩺 Specialty Charts in Helix

Helix supports 32 medical specialty charts.

Each specialty has its own medical chart, designed specifically for that department.


📌 Key characteristics

  • Every specialty chart is tailored to its clinical needs

  • Despite specialty differences, the chart layout remains consistent

  • Doctors always document within the same structural framework

ℹ️ Notes

  • Each specialty chart is documented separately in the Helix Default Charts KB

  • Dental charts require a specific setup

  • It is possible to build custom charts
    (referenced in Medical Templates Reports KB and Medical Templates KB)

🧠 Documenting Clinical Information in the Specialty Chart

The middle section of the Medical Chart is where doctors document clinical findings.

✍️ Documentation methods supported

  • Structured fields using dropdowns

  • Free-text entry

  • Uploading images (before and after)

  • Drawing directly on existing sketches

All documentation entered here is saved as part of the patient visit.

🧬 General Medical History

📍 Where it appears

  • Displayed in the top section of the Medical Chart

🧾 How it is populated

  • Initially entered by nurses during Screening

✏️ Doctor access

  • General Medical History is editable by doctors

  • Any updates made during the visit are recorded against the patient

(For detailed Screening behavior, refer to the Screening KB.)

🧾 Assigning ICD-10 Diagnosis Codes

📍 Where to find ICD-10

  • The ICD-10 Diagnosis section appears at the bottom of every medical chart

🧩 How ICD-10 works

  • The field supports multiple ICD-10 codes

  • The first code selected is automatically marked as Primary

  • Any additional codes are treated as Secondary

  • This behavior is default and requires no additional setup

⚠️ Enforcing ICD-10 Entry Before Exiting a Chart

Helix provides an option to ensure at least one ICD-10 code is entered before a doctor leaves the chart.

⚙️ Configuration path

  • Go to Control Panel → Account Settings → Branch Settings

  • Enable Require ICD-10 in medical templates

🔔 What happens when enabled

  • If a doctor or therapist attempts to exit a medical chart without an ICD-10 code,
    a notification appears prompting them to add at least one diagnosis code before proceeding

📝 Notes

  • ICD-10 entry is part of standard clinical documentation

  • Multiple diagnosis codes can be recorded per visit

  • General Medical History and Specialty Chart notes are documented separately but within the same visit