How to Document ICD-10 Diagnoses in Afya Wingu: Step-by-Step Guide to Section 7 (Diagnoses)

How to Document ICD-10 Diagnoses in Afya Wingu: Step-by-Step Guide to Section 7 (Diagnoses)

Welcome back to Afya Wingu Healthcare Management System.
In this article, we’re taking you through Section 7: Diagnoses — the stage where clinicians assign standardized ICD-10 diagnoses for proper treatment, reporting, billing, and continuity of care.

For this walkthrough, we continue using the patient record for Maxwell Wright, age 20, male, with a visit date of November 25, 2025. Previous sections of his clinical encounter — including Chief Complaint, Vital Signs, HPI, Medical History, Assessments, and Medications — have already been completed.

Now it’s time to assign accurate clinical diagnoses.

🔷 Understanding Section 7 — Diagnoses

Section 7 allows you to:

  • Search for ICD-10 conditions
  • Set the Primary Diagnosis
  • Add Differential Diagnoses
  • Record your clinical reasoning
  • Save changes with full traceability

Everything is designed to help clinicians document diagnoses quickly and accurately.

🔷 ICD-10 Search Panel

On the left side, you’ll see the diagnosis search tools. These help you find the correct ICD-10 code using disease names, symptoms, or code numbers.

1. Search Bar

Simply type at least 3 characters into the search field.

Examples:

  • Typing mala → shows results like Plasmodium falciparum malaria (B50)
  • Typing disease names: “diabetes”, “asthma”
  • Typing symptoms: “fever”, “headache”
  • Typing ICD-10 codes: “B50”

💡 Pro Tip:
Use common medical terms — the system auto-suggests matching ICD-10 entries as you type.

2. Filter by Category

Below the search bar, you’ll find helpful category filters, such as:

  • 🟢 ID — Infectious Diseases
  • 🟡 Diabetes
  • 🔵 Respiratory Conditions

Clicking any category narrows your search results.

3. Selecting a Diagnosis

Each search result displays:

  • Full disease name
  • ICD-10 code
  • Short classification description

You can choose how to apply the diagnosis:

  • Set as Primary → assigns the main diagnosis
  • Add to Differential → lists it as a possible alternative

Example:
If malaria is suspected:

  • Set B50 — Plasmodium falciparum malaria as the Primary Diagnosis
  • Add B50.8 and B52 as Differentials to rule out complications or alternative malaria types

🔷 Diagnostic Impression (Primary Diagnosis)

This box displays the main diagnosis for the visit.

Example:
Plasmodium falciparum malaria — ICD-10 B50

Important rules:

  • You can assign only one primary diagnosis per visit
  • To change it:
    1. Click Clear
    2. Search again
    3. Select a new primary diagnosis
    4. Click Save Information

⚠️ Remember:
Changes are not saved until you click the Save Information button.

🔷 Differential Diagnosis

This section lists any potential alternative diagnoses the clinician has considered.

Example differential list:

  • B50.8 — Other severe P. falciparum malaria
  • B50.0 — Cerebral malaria
  • B52 — Plasmodium malariae malaria
  • B52.0 — P. malariae malaria with nephropathy

These options help document clinical reasoning when diagnostic confirmation is still pending.

To remove an item, click the “x” icon next to it — then press Save Information.

🔷 Clinical Notes

This free-text section is where clinicians explain why they selected the diagnosis.

Example note:

“Patient presents with fever, low SpO₂, and epigastric pain. Rapid malaria test positive. No signs of cerebral or renal involvement. Primary diagnosis: uncomplicated P. falciparum malaria. Differentials considered: typhoid, dengue, pneumonia.”

Tips for good notes:

  • Be clear and concise
  • Document reasoning
  • Mention tests used to support diagnosis
  • List conditions ruled out

These notes provide crucial insight for other clinicians reviewing the case.

🔷 Save Your Work

This is the most important step.

Click the blue “Save Information” button any time you:

  • Add a new diagnosis
  • Change the primary diagnosis
  • Add/remove differentials
  • Edit clinical notes

You’ll also see a timestamp such as:

Last saved: November 27, 2025 | Updated By: Malaika Center

This ensures transparency and accountability.

🎉 Conclusion

You’ve now learned how to use Section 7: Diagnoses in Afya Wingu:

  • Search ICD-10 codes
  • Assign a Primary Diagnosis
  • Add Differential Diagnoses
  • Record clinical reasoning
  • Save with full audit trail

Accurate diagnosis documentation supports better treatment, reporting, billing, and continuity of care.

Up Next:

➡️ Section 8: Management Plan — outlining treatment, follow-ups, and referrals
➡️ Section 9: Prescription — generating prescriptions for medications and labs

Thank you for choosing Afya Wingu — making healthcare documentation simple, accurate, and fully traceable.