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How Do I Add DSM Codes to My Notes?

You can add DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) codes to your clinical notes or reports within PatientNotes to h...

You can add DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) codes to your clinical notes or reports within PatientNotes to help document diagnoses in a standardized format.


🧠 How to Add DSM Codes:

Option 1: Add Manually in Notes or Prompts

  • Include the DSM code and description directly in your clinical note or custom prompt.

  • Example:

    Diagnosis: Major Depressive Disorder, Single Episode, Moderate (DSM-5 Code: 296.22)

Option 2: Include in AI-Generated Output

  • You can modify your prompt to instruct the AI to include a DSM code.

  • Example prompt addition:

    “Include the appropriate DSM-5 diagnosis code with a brief description based on the clinical presentation.”

Option 3: Post-Generation Edit

  • After generating a letter or summary, you can manually insert or adjust the DSM code in the final output if needed.


⚠️ Disclaimer on Accuracy:

While PatientNotes can help suggest or insert DSM codes, it is your clinical responsibility to verify their accuracy based on the patient’s presentation, criteria, and your professional judgment.

  • DSM codes are complex and may require interpretation within a broader diagnostic framework.

  • Always double-check that the code used matches the latest version of the DSM and reflects the clinical assessment.


🧩 Best Practices:

  • Include full code + description for clarity.

  • Avoid using AI suggestions without clinical validation.

  • Keep a reference DSM-5 manual or verified digital resource on hand for coding decisions.


Questions?

If you’d like help structuring your prompt to include DSM codes effectively, email us at [email protected].

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