Recording a Diagnosis

The Diagnoses panel records what you think is wrong with the patient, chosen from a national code list rather than typed as free text. Injuries go in Suspected Injuries; everything else goes here.

Overview

Diagnoses sits beside Suspected Injuries in the patient record, and the split between them is simple: did something hit them? Injuries. Did something happen to them? Diagnoses. A fractured tibia belongs in Suspected Injuries. Chest pain, an asthma attack or heat exhaustion belong in Diagnoses.

Every diagnosis is chosen from the NHS emergency care diagnosis list — the same code list emergency departments use — so what you record means the same thing to the hospital that receives the patient as it does to you. You pick a term from a search box; you cannot type your own.

Each diagnosis carries an optional certainty (Confirmed or Suspected) and an optional note, and appears on the patient report form alongside injuries.

The Diagnoses panel is switched off by default. It only appears once IndieBase has enabled it for your team. If you can't see it in the sidebar, that's why — see Troubleshooting below.

Before You Start

• The Diagnoses panel must be enabled for your team. Contact support if you want it turned on.
• A patient must already exist on the job.
• Your device needs to have been online at least once since the panel was enabled, so it can download the diagnosis list. After that the panel works fully offline.
• The panel can also be hidden by your team's configuration template, in the same way as any other panel.

Recording a Diagnosis

Step 1: Open the panel and search

Tap Diagnoses in the sidebar, then tap the Search diagnoses box.

• Start typing and the list filters as you type — search on any word in the term, not just the first.
• Or tap the dropdown arrow without typing to browse the first 50 terms.

Step 2: Tap the term you want

Tapping a term stages it — nothing is on the record yet.

Step 3: Choose Confirmed or Suspected

The staged term appears below the search box with the question Is this confirmed or suspected? and two buttons: Add as confirmed and Add as suspected.

Choosing the certainty is the add action. There is no separate Save button, and nothing is pre-selected — the app will not put a clinical claim in your mouth that you did not make.

• Confirmed — you are settled on this diagnosis.
• Suspected — this is your working diagnosis and it is still provisional.

To back out without recording anything, tap the red cross beside the staged term.

If your team has the certainty control switched off, this step doesn't appear — tapping the term records it straight away with no certainty against it.

Why Some Results Are Greyed Out

Search results are grouped, and two of the groups are deliberately shown but not selectable. They are greyed out rather than hidden so you can see that IndieBase knows the term — a search that returns silence is what makes people give up and write free text somewhere else.

"Also found in Suspected Injuries" — the Injury badge

Trauma terms carry an Injury badge. They belong in the Suspected Injuries panel, which uses your team's own injury list. When your search matches one, a strip appears below the search box:

Your search also matched injuries — record those in the Suspected Injuries panel.

Tap Open Injuries to jump straight there.

The two lists are organised differently, so your search text is deliberately not carried across — you'll search again in the injuries picker using its own region / category / specific structure.

"Procedures — not a diagnosis" — the Procedure badge

A handful of terms in the national list are procedures rather than diagnoses (palliative care, specimen collection, attention to sutures, and similar). They carry a Procedure badge and a line at the bottom of the list explaining that greyed rows are procedures and can't be added here. Record what you did in Interventions instead.

Editing a Recorded Diagnosis

Each recorded diagnosis shows the term, its certainty badge, and its SNOMED code. Two buttons sit on the right of every row:

• Pencil — opens the row for editing. You can switch the certainty between Confirmed and Suspected, and add or change an optional Notes entry. Tap the tick to close the editor.
• Bin — removes the diagnosis from the record.

Both work offline, and both work even if the diagnosis list itself hasn't downloaded.

What Ends Up on the Patient Report

Diagnoses appear on the PRF — the on-screen report, the PDF, and any copy sent to a hospital or to the patient — in their own Diagnoses section beside Injuries. Each entry shows the term, its certainty as a coloured badge, and your notes if you added any.

The SNOMED code is stored against the record for audit and for sharing with other systems, but it is not printed on the report: the term is what a clinician reads.

Every PDF also carries the SNOMED CT licence notice and the code list release in the footer. See Clinical Terminology for the full attribution and what release your instance is on.

Working Offline

The diagnosis list is downloaded to your device and stored there, so searching and recording work with no signal.

If the list hasn't downloaded yet, the search box is replaced by a blue notice:

Diagnosis list not downloaded — reconnect once to enable coding; you can still save the record.

Everything else keeps working: diagnoses already on the record stay visible and editable, and the rest of the patient record saves and syncs as normal. Connect to a network once and the list downloads in the background.

Tips & Best Practices

• Record the working diagnosis early as Suspected, then switch it to Confirmed later rather than waiting until you're certain. The certainty toggle on the row takes one tap.
• Use Notes for the detail the code can't carry — the code list is deliberately coarse, and a one-line note is what makes the entry useful to whoever reads the PRF next.
• If you can't find a term, try a different word. Search matches any word in the term, so "chest" will find terms that don't begin with it.
• Trauma goes in Suspected Injuries, every time. Recording it in Diagnoses instead would leave it out of your team's injury reporting.
• More than one diagnosis is fine. Add each one separately; the panel badge shows the count.

Troubleshooting

I can't see the Diagnoses panel in the sidebar. The panel is off by default and is enabled per team. Contact support to have it switched on. If it was working and has disappeared, check with your team administrator — it can also be hidden by the configuration template in use.

The panel says the diagnosis list hasn't been downloaded. Your device has never had the list. Connect to a network with the app open and it downloads in the background; the search box replaces the notice once it's there. Existing diagnoses stay editable in the meantime.

I searched for a fracture and the result is greyed out. Trauma terms carry an Injury badge and are recorded in the Suspected Injuries panel instead. Tap Open Injuries on the strip below the search box.

I searched for a procedure and can't select it. Procedures carry a Procedure badge and can't be added to this panel. Record what was done in the Interventions panel.

I'm not asked whether the diagnosis is confirmed or suspected. Your team has the certainty control switched off, so diagnoses are recorded without one. Ask your team administrator if you need it turned back on.

Can I type my own diagnosis? No. The panel only accepts terms from the national code list — that's what makes the record shareable and reportable. If nothing fits, choose the closest term and explain in the Notes field on the row.

I recorded a diagnosis on the wrong patient. Tap the bin icon on the row to remove it, then record it on the right record. Removal works offline and syncs like any other change.

Related Features

• Filling In the Patient Record — the rest of the panels, including Suspected Injuries and Interventions
• Marking a Job as Done — closing the record once documentation is complete
• Clinical Terminology — the SNOMED CT licence, the code list release, and how historical records stay readable