Medical History: Problem List

The following topics are discussed on this page. Use the links to jump to the desired subject:

Introduction to the Problem List

About Health Status Observation

About Problems

About Impairments

To filter the problem list

To access the Clin-eguide database

To add a health status observation

To add a problem

To add a goal to a problem

To edit a problem

To remove a problem

To add an Impairment

To edit an Impairment

To remove an Impairment

To document No Known Problems

To document No Change

To view the change log

To generate the CCD (Continuity of Care Document)_

Introduction to the Problem List

The problem list allows you to capture, maintain, and display all problems and diagnoses associated with a patient including the onset and resolution dates and chronicity of the problem. This screen allows you to view current (unresolved) and historical (resolved) problems, and allows you to resolve problems moving them from the current list to the historical list. A chronological change log is also available, which records the original content, change reason, and an audit trail of the user ID and date/time stamp.  

To access the problem list page, use one of the following methods:

• (Preferred method) From the Main page, use the Select button to select the appropriate patient using the drop-down list. Then, click the Problem button. The Medical History: Problem page is displayed.

OR

• Click the Problem button on the Main page. The Patient Search box is displayed. Begin typing the patient information. See Selecting Patients for additional details on using this feature.

Once the patient is selected, the patient's basic episode information is displayed in the yellow bar at the top of the screen, including: patient name, DOB, and medical record number. The page displays three sections: Health Status Observation, Problems and Impairments.

About Health Status Observation

The Health Status Observation section provides a current status of the patient's health. The patient can only have one associated health status observation at a time. Use the following buttons to access additional information or take action.

About Problems

In the Problems section, each problem is displayed along with the chronicity, occurred date, resolved date, and verified by information. In addition, the following function buttons are accessible for each problem in the list:

About Impairments

This section is used to create, edit, and maintain acute or ongoing impairments to the patient's cognitive and functional status. You can view, add, and remove impairments to the list. In the Impairments section, each impairment is displayed along with the type, chronicity, occurred date, resolved date, and verified by information. In addition, the following function buttons are accessible for each impairment in the list:

To filter the list

The problem history can be filtered and sorted so that the list provides information in a customized view. The default view displays all resolved and unresolved problems by occurred date (in reverse chronological order). You can change the view based on the following options in the Filter field:

• Show All: Displays all problems

• Resolved: Displays all problems that have a chronicity of Resolved

• Unresolved: Displays all problems that have a chronicity other than Resolved

• Active: Displays any problems that are not Inactive and are not Resolved

• Inactive: Displays problems that are Inactive

To change your view, use the drop-down lists in the Filter and Sort fields (Occurred Date or Description) to select the desired view options. Once selected, the list is resorted accordingly.

Back to top

To access the Clin-eguide™ database

Clin-eguide™ is a clinical decision support database of evidence-based guidelines, powered by a Healthland third party partner. To access this database, click the Clin-eguide™ button. This launches a portal page to search for evidence-based research and documentation. See the Clin-eguide™ section for more details.

The use of the Clin-eguide™ database requires licensing and setup. Contact your Account Manager for details.

To add a health status observation

1. Click Add Health Status Observation. The Add Health Status Observation box is displayed.
2. In the Observation field, use the drop-down list to select the appropriate health status.
3. In the Notes field, enter any additional notes regarding the observation.
4. Click Save.

To add a problem

1. Click Add Problem. The Add Problem box is displayed.

2. In the Problem field, you can enter the problem in free text or you can select a problem from the database (SNOMED-CT or ICD9). To select a problem from the database, begin typing part of the problem description. (In this field, you can also type in the ICD9 code. When an ICD9 codes is selected, the ICD9 code and SNOMED code are both displayed in the Details of the problem.) A list of possible matches appears as you type. You can continue typing to narrow down the list. Highlight and select the desired problem. The text in the bracket is the search text; The text after the brackets is the actual description of the item selected. [See Also: Using the SNOMED-CT database]

If you add a free text problem, a warning message is displayed that states, This is a free text problem. No interaction checking can be performed.  

3. In the Chronicity field, use the drop-down list to select the appropriate level of chronicity. Valid options are: Acute, Chronic, Recurring, Resolved, Active, Inactive, or Terminal. (Note: The Terminal option is used to identify if the patient's condition is terminal, which, in some cases excludes them from Meaningful Use reporting measures.)

4. If this problem is a current health concern, check the Health Concern box. An icon is displayed next to the item ion the page to flag it as a current concern.

5. In the Occurred and Resolved date fields, use the drop-down list to select Day, Month, or Year. In the  blank date field to the right, click the calendar to select the date. The date is automatically formatted according to the selected day, month, or year.

6. The Age field displays the calculated age of the patient based on the DOB and the Occurred field. If you enter a value in the Age field, the Occurred year is also automatically calculated/displayed.

7. In the Notes field, you can type a free-text message about the problem.

8. Click Save and Add More to add the problem and remain in the window to add additional problems. Or, click Save and Close to save your work and return to the problem list.

Back to top

To add a goal to a problem

To add a goal to a problem, click the Add Goal button (green plus sign) located next to the problem. The Add Goal box is displayed.

1. In the Type field, select Procedure, Vital Signs, or Non-specific.  If you select Vital Signs, additional fields are displayed where users can select Vital Sign Type and Range.
2. In the Description field, begin by typing the first few letters of the problem. Matches in the SNOMED database to the typed text are displayed. (Note: There will not be ICD9 codes in this selection list.)
3. Select the appropriate goal from the list.
4. In the Notes field, type specific instructions related to the goal.
5. In the Status field, select the appropriate status: Active or Resolved.
6. Then, click Save and Close. Or, if you have additional goals to add, click Save and Add More.

To document No Known Problems

When a patient has no known problems, check the No Known Problems box. The Source of Information is displayed. In the Source field, use the drop down list to select the source of the information. Then, click Save. Note: If the No Known Problems radio button is not displayed, there are problems already entered on the patient's record. To get this option to display again, you must remove any patient problems from the list.

To edit a problem

1. Click the Edit button next to the problem you want to edit. The Edit Problem box is displayed. Edit any of the fields as needed. See To add a problem above for field descriptions.

2. In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.

3. Click Save to save your changes and return to the problem list, or click Close if you want to cancel your changes.

Back to top

To remove a problem

1. Click the Remove button next to the problem you want to remove. The Remove Problem box is displayed.

2. In the Reason field, use the drop-down list to select a reason for removing the problem. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.

3. Click Remove to continue. You are returned to the problem list with the problem now removed.

To add an Impairment

1. Click Add Impairment. The Add Impairment box is displayed.

2. In the Impairment field, you can enter the in free text or you can select an item from the database (SNOMED-CT). To select an item from the database, begin typing part of the impairment description. A list of possible matches appears as you type. You can continue typing to narrow down the list. Highlight and select the desired item. (Note: There will not be ICD9 codes in this selection list.)

If you add a free text problem, a warning message is displayed that states, This is a free text problem. No interaction checking can be performed.

3. In the Impairment Type field, select Cognitive or Functional, depending on the type of impairment.

4. In the Chronicity field, use the drop-down list to select the appropriate level of chronicity. Valid options are: Acute, Chronic, Recurring, Resolved, Active, Inactive, or Terminal. (Note: The Terminal option is used to identify if the patient's condition is terminal, which, in some cases excludes them from Meaningful Use reporting measures.)

5. If this impairment is a current health concern, check the Health Concern box. An icon is displayed next to the item ion the page to flag it as a current concern.

6. In the Occurred and Resolved date fields, use the drop-down list to select Day, Month, or Year. In the  blank date field to the right, click the calendar to select the date. The date is automatically formatted according to the selected day, month, or year.

7. In the Notes field, you can type a free-text message about the problem.

8. Click Save and Add More to add the problem and remain in the window to add additional problems. Or, click Save and Close to save your work and return to the problem list.

To edit an Impairment

1. Click the Edit button next to the item you want to edit. The Edit Impairment box is displayed. Edit any of the fields as needed. See To add an Impairment above for field descriptions.

2. In the Reason field, use the drop-down list to select a reason for the edit. To enter a reason that is not listed, select Other (See notes) from the list and type in the required free-text reason in the Other Reason field.

3. Click Save to save your changes and return to the problem list, or click Close if you want to cancel your changes.

Back to top

To remove an Impairment

1. Click the Remove button next to the item you want to remove. The Remove Impairment box is displayed.

2. In the Reason field, use the drop-down list to select a reason for removing the item. To enter a reason that is not listed, select Other (See notes) from the drop-down list and type the required free-text reason in the Other Reason field.

3. Click Remove to continue. You are returned to the problem list with the item now removed.

To verify the Problem List (No Change)

The No Change option allows you to indicate that you have reviewed and verified that the problem list is correct and hasn't changed since the last assessment/review.

1. Click No Change located at the upper right-hand corner of the window.

2. A message box is displayed with the message, Would you like to mark all problems as being reviewed and verified? Select Yes to indicate you have reviewed and verified the problem list, and click Save; or select No or click Close if you do not want to perform the verification at this time. Once reviewed, the user name and date/time displayed in the Verified  field is updated.

To view the change log

A change log is available to view all details of a problem change. The log records when a problem is added, edited, or removed, and contains the login name of who made the change, a reason for the change, and both the original and new values of the problem description, chronicity, notes, occurred date, and resolved date.

There are two ways to access the change log:

• Click View Change Log at the top of the screen to view changes for all problems.

• Click the button next to a particular problem to view changes for only that problem.

On the Problem Change Log page, problems are displayed according to the date/time they were changed, with the most recent change first. You can alter your view to display only added, edited, or removed problems, as well as, sort the problems by description. To change your view, use the drop-down lists in the Filter and Sort fields to select your desired view options. Once selected, the list is resorted accordingly.

The default view allows you to view a quick list of problem changes showing only the date/time, user, problem, and action (added, edited, or removed). Click the show details icon next to a particular problem to display additional details for that item. Click Show All Details to display additional details for all the item changes.

Click Back to leave the change log and return to the problem list.

To generate the CCD (Continuity of Care Document)

The CCD is a clinical summary document generated from the patient's clinical information, including insurance providers, advance directive information, problem list, and medication information.  This document opens in a new browser tab, where it can be e-mailed, saved, and/or printed to the patient and/or another healthcare provider. To generate the CCD, click Generate CCD.

Back to top

Related Topics