Canvas provides powerful tools to help clinicians document, update, and manage patient conditions efficiently and accurately. Clinicians can record new diagnoses, assess and update existing conditions, resolve inactive ones, and revise diagnoses while maintaining historical data. With the ability to manage coding gaps, Canvas also helps ensure accurate documentation, supports billing compliance, and streamlines workflows to improve clinical and operational outcomes.

Diagnosing a Condition

The Diagnose command is used to record new conditions in a patient’s chart, creating a clear and structured entry for accurate clinical documentation. It can be initiated from the patient chart or directly from the patient summary, where it automatically inserts the Diagnose command wherever the cursor is focused.

When using the Diagnose command, the following fields are available to provide detailed and meaningful documentation:

• Background: Completing this field is optional but helpful for establishing a comprehensive history.

• Approximate Date of Onset: Enter a free-text start date, such as “yesterday,” “last week,” “3 years ago,” or “2015.”

• Today’s Assessment: Summarize clinical thinking around the condition, synthesizing subjective and objective data from the exam.

Once saved, the condition is immediately visible on the patient summary as an active entry, ensuring seamless tracking and documentation.

Assessing a Condition

The Assess Condition command updates and documents progress for an existing condition. You can add this command directly to a note or by hovering over the condition in the Patient Summary and clicking Assess, which inserts the command at the current cursor position. If a note is note selected, the command will go into a new Chart Review note.

• Carry Forward: If the data fields from a previous Diagnose or Assess command need to be transferred to a new Assess command for the same condition, follow these steps:

  • Click the triple dot for the new Assess Command

  • Click Carry Forward from the dropdown menu

  • Contents of the matching fields from the previous command will replicate in the new command

• Background: If the background for a condition was previously documented, the system automatically carries forward the most recent background details from prior Diagnose or Assess commands. This ensures continuity when managing a patient’s condition

  Any new information entered into the Assess command fields will overwrite existing content. This ensures the record remains accurate and up-to-date for the next time it is carried forward

• Status: provide current condition of status

  • 🟢 Improved

  • 🔘 Unchanged

  • 🔴 Deteriorated

  

• Today's Assessment: Based on condition status, update observations made at current visit

  

• Status: provide current condition of status

  • 🟢 Improved

  • 🔘 Unchanged

  • 🔴 Deteriorated

  

• Today's Assessment: Based on condition status, update observations made at current visit

  

Historical Assessments

Clicking on a condition in the Patient Summary opens a modal displaying:

• Background: Displays the condition’s most recent and historically documented background information.

• Associated Medications: Lists medications related to the condition.

• Comprehensive History: Provides a timeline of all prior assessments, including:

• Observations from previous visits.

• ICD-10 diagnoses, both original and updated, entered via the Change Diagnosis command.

Documenting Past Medical History

The Past Medical History command is designed to document a patient's medical history. It captures conditions that are no longer active but may still impact clinical decision-making now or in the future.

• Approximate Start Date: Free-text date, such as last week, 3 years ago, 2015 or specific date if known

• Approximate End Date: Enter a free-text date similar to the start date format.

• Show on Condition List: Toggle to display the condition on the Conditions List in the left panel of the patient’s chart.

• Comments: Any additional notes (up to 1000 characters).

Resolving a Condition

The Resolve Condition command closes an active condition listed for the patient. You can execute this command by adding it directly to the note or by clicking Resolve next to the condition in the Patient Summary.

• Rationale: reason for resolving the condition

• Show on conditions list: If selected, resolved conditions will appear at the bottom of the Patient Summary in gray non-bolded text

Changing a Condition

The Change Diagnosis command enables updating the name or ICD-10 code for a condition without losing historical data, which is particularly useful when new information leads to a more precise diagnosis.

• New Diagnosis: Select the updated ICD-10 diagnosis to replace the original

  When searching for the updated diagnosis, you may utilize natural language or ICD-10. When searching by ICD-10, omit the decimal point for the best search experience

• Background: If needed, add additional background information to provide context for the updated diagnosis.

• Today's Assessment: Document any observations made during the current visit to reflect the revised condition.

When the note is billable, the Change Diagnosis command ensures the billing footer and claim are updated. The new ICD-10 code is added for the revised condition, and the previous ICD-10 code associated with the original diagnosis is automatically removed.

Coding Gaps

Coding gaps are potential opportunities to enhance the accuracy of a patient’s diagnosis coding, especially for risk adjustment programs like Hierarchical Condition Categories (HCC). These gaps occur when a diagnosis or condition relevant to risk adjustment is missing or not properly documented in the patient’s record

Creating a Coding Gap

Document a potential coding gap by suggesting a diagnosis that may be missing from the patient’s record.

• Add the Create Coding Gap command to a note and complete fields

  • Heading: Diagnosis being evaluated for coding gap

  • Status: Select Created (default) or Create and Validate

  • Date: Will default to day command was created

  • Notes: Any added details pertaining to the coding gap

• Once the command is committed, a protocol card will be created informing a coding gap needs to be reviewed for validation

  

Validating a Coding Gap

Confirm the suggested coding gap as clinically relevant and document its validity in the patient’s record.

• Click Validate in the protocol card or manually enter the Validate Coding Gap command

  • Heading: Name of condition being validated

  • Status: Choose Valid or Invalid to indicate validity of diagnosis

  • Date: Will default to day command was created

  • Note: Will carry forward notes entered in the Create Coding Gap command. Notes can be kept as is or modified, if necessary

• If the command is committed as Valid, the diagnosis will reflect in the patient summary under Coding Gaps

  

Review Details of Validated Coding Gaps

• Click the condition listed under Coding Gaps in the patient summary

• A modal will open with the following information

  • Heading: Coding gap ICD-10 description and code

  • Validated: Date the command was committed and who performed it

  • Note: From the Validated Coding Gap command, if applicable

  • Reference: Any linked resources if added to the command

• Condition can be assessed or deferred from this modal or the commands can be added to the note

  

Defer Coding Gap

Temporarily postpone action on a coding gap when additional information or follow-up is needed before making a decision.

• Click Defer from the patient summary or add the Defer Coding Gap command to the note

• Click Record

  

• Coding gaps that are deferred will display back on the patient summary or in the Assess Coding gap command after 5 days. At that time it can be deferred again or assessed.

Assess Coding Gap

Review the coding gap and either accept or refute it.

• Click Assess from the patient summary or add the Assess Coding Gap command to the note

  • Heading: Name of condition being assessed

  • Status: Select Accept and Diagnose or Refute

  • Note: Will carry forward from the note that was documented in the Validate Coding Gap command

  • Diagnose: Official diagnosis of the assessed condition

  • Background: Will carry forward from the note that was documented in the Validate Coding Gap command. Can be modified, if necessary

  • Today's Assessment: What was assessed at the current visit

• If the coding gap is accepted once committed, the diagnosis will drop to the conditions list in the patient summary.

  

• If refuted, close the coding gap by documenting the reason it is not valid in the Note field and commit the command to remove the coding gap

  

FAQ & Troubleshooting

Q: How can I add a diagnosis/ICD-10 code?

A: Diagnosis codes cannot be added manually. We update our ICD-10 codes in accordance with CMS on April 1 and Oct 1 every year.