Health Problem Documentation

A list of active health conditions (“Problem List”) appears in all Connect Care charts in all contexts. It lists diseases, disorders, injuries and health conditions that have an impact on, or could be impacted by, a patient’s current care.

For a medical condition to be added to the Problem List, it should be persistent, clinically relevant and specific. Inactive or past problems can be listed elsewhere in the chart, usually as part of the patient’s medical or surgical history.

Health problems identified in the Problem List are standardized labels for conditions, diagnoses or risks. They determine which ordering tools, documentation aids, coordination aids, decision supports, patient resources and professional billing prompts are offered to speed workflows.

All prescribers share responsibility to update and manage health problems, especially those they have entered themselves. Problem List reconciliation (resolve, revise or promote) occurs at first encounter, care transitions or appropriate intervals.