The Problem List Problem

We’ve all been there. Our look of utter contempt when we see a 3-page, unedited problem list.

According to AHIMA, a problem list includes: “chronic conditions, diagnoses, functional limitations, visit or stay-specific conditions, diagnoses, or signs and symptoms.” A well maintained problem list paints the most precise clinical picture of your patient. Problem lists must be maintained over the lifetime of the patient. But whose job is it to fix it? An outdated, cluttered problem list is everyone’s problem. Before recommending whose job it is to maintain the list, let’s define some of the common terminology associated with the it.

Problem List Definitions:

Active patient: a patient that is being cared for by at least one team in your organization (within the last 3 years).

• Not to be confused with definitions for New/Established CPT definition

Inactive patient: a patient that does not have any care teams who are responsible for, or caring for them.

• Discharged patients are not considered inactive patients (usually facility setting use)
  • Care may continue in patient’s home or other facility
• Deceased patients (own categorization)

Problem list: Is a summary that chronicles the most important health problems facing a patient. This includes non-transitive illnesses or diseases, injuries suffered by the patient, and other factors that affect the health of an individual patient, usually identifying the time of occurrence, or identification and resolution.

The EMR summary (i.e., Problem List) of the patient’s medical diagnosis information must include at least the following:

• Epic Policy Standards and/or National Standards
• Any known significant medical diagnoses and conditions
• All significant operative and invasive procedures affecting current health
• Every known adverse and allergic reaction

Healthcare provider: a physician, ACP (nurse practitioner, nurse midwife, physician assistant), or other licensed individual authorized to write patient care orders.

Significant medical diagnosis/condition: any non-transient problem that is significant enough to be relevant to the health of the patient going forward, including significant signs or symptoms that are undiagnosed (i.e., chronic abdominal pain) as well as diagnoses that are confirmed and relevant to future care.

Significant operative and invasive procedures: any operative or invasive procedure that is significant enough to be relevant to the health of the patient going forward.

Now that we understand the basic terms, what is required “best practice” to be included in the problem list? Let’s take a look at the national standards that apply.

Health Level Seven International’s Electronic Health Record System Functional Model: Best Practice EMR Documentation

1. A system must capture, display and report all active problems associated with the patient.
2. A system must capture, display and report a history of all problems associated with a patient.
3. A system must provide the ability to capture the onset date of the problem.
4. A system must provide the ability to capture the source, date and time of all updates to the problem list.
5. A system must provide the ability to deactivate a problem.
6. A system should allow manual order/sort of the problem list.
7. A system should provide the ability to capture the chronicity (chronic, acute/self-limiting, etc.) of a problem.
8. A system should provide the ability to reactivate a previously deactivated problem.
9. A system can provide the ability to associate encounters, orders, medications and notes with one or more problems.

Here at UT Health, we have EPIC to assist us in meeting these documentation standards. In fact, we have an entire pdf booklet that explains the what, when, where, why, and how our ambulatory physicians and clinicians are to manage the patient problem list in Epic. Interestingly, the last few pages also give some insight on how to document HCC conditions. Though UTH is not contracted for payment via HCCs, our Medicare Advantage contractors are. So, they look to our physician documentation to support their HCC coding reported to CMS.

Finally, to answer the burning question of whose job is it anyway? It’s every physician/clinician on the patient’s care team’s job to keep their portion of the problem list updated and well maintained.

Remember, a well maintained problem list not only ensures the most accurate portrait of the patient’s clinical condition, meets quality care standards, assists with patient safety, it also reduces physician stress as well. Do your part to keep the problem list tidied up.

Stay tuned, more on the problem list and HCC coding to come.

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