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Problem List Guidance in the EHR. Appendix A: Sample Policy and Procedure Template

There is no one-size-fits-all approach to developing and using problem lists, but rather multiple approaches to be considered. This sample policy is intended to provide guidance for organizations developing problem list policy. Organizations must take national standards and organizational operation into account when developing problem list policy.

Sample Problem List Policy

POLICY STATEMENT

Patients receiving continuing care in the acute and ambulatory setting are required to have a problem list as part of the medical record. The problem list is intended to promote continuity of care over time and among providers for the patient.

PURPOSE

The purpose of this policy is to provide guidance on initiating and maintaining the patient problem list. When used properly and consistently, the problem list serves as a valuable tool in patient care management. The problem list compiles all past and current patient problems, including social, psychological, and medical problems, in one location. At a glance, providers can determine which problems are active or resolved and formulate treatment plans accordingly. Additionally, the problem list serves as a communication tool and aids in the evaluation and treatment decision when the patient is referred to a specialty physician for care.

DEFINITIONS

Active patient: a patient who has had a visit to any [Facility Name] location within the previous three years.

Problem list: a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution. The electronic summary of the patient's medical information includes at least the following:

  • Items from organization-defined national standards
  • Known significant medical diagnoses and conditions
  • Known significant operative and invasive procedures affecting current health
  • Known adverse and allergic reactions

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

Significant medical diagnosis/condition: any nontransient 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.

PROCEDURE

  1. All clinic patients will have a problem list initiated and maintained by the third visit. For inpatients treated for chronic or critical conditions, problems are entered into the problem list upon discharge.
  2. All providers should review the problem list, add problems, and enter updates as appropriate.
  3. Primary care providers have ultimate responsibility for maintaining an accurate problem list.
  4. To maintain usefulness of the problem list, problems will be entered in a timely manner.
    (Organizations should consider further defining time specifications.)
  5. Only approved staff will enter problems. Medical directors will identify approved staff within their clinic/department.
  6. All problems will be listed as active until a licensed independent practitioner changes the problem to "resolved."
  7. If copy/paste functionality is utilized, the entry must be edited to ensure documentation integrity.
  8. Problems will include:
    • Items from organization-defined national standards
    • Known significant medical diagnoses and conditions
    • Known significant operative and invasive procedures affecting current health
    • Known adverse and allergic reactions
  9. All entries, when possible, will utilize a standard vocabulary to ensure classification of data for rules, alerts, and potential reporting. HIM professionals and clinical users will determine whether a classification or vocabulary system should be used for the entries on the problem list.
  10. If directed by a specialty, approved by the HIM committee, and resources allocated, HIM coders or routine automated entry will be allowed to enter designated problems onto the problem list. Corrected June 2015: Only providers will be allowed to enter or edit designated problems or diagnoses onto the patient problem list; this is not within the role or scope of coding or coding audit professionals.
  11. Development of system level problem folders requires approval by the HIM committee.
  12. Abbreviations will be avoided in the problem list to ensure clear communication among all disciplines.
  13. The HIM committee must approve all rules, alerts, and system-generated problems at least one month before implementation. System-generated problems will be updated with resolved status by the requesting provider group.
  14. The problem list is considered a permanent part of the medical record and is included in the designated record set.

REFERENCES

[Include any references used to develop problem list policy]

RELATED POLICIES

1103.00 Medical Record Documentation

REVIEW/REVISION DATES

[Provide original and revised dates for problem list policy]

APPROVAL GROUPS

[Outline groups that have approved problem list policy]