Problem List Documentation Norms

What is it?

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.

Health problems identified in the Problem List are standardized labels for conditions, diagnoses or risks. They map to codified terminology. Accordingly, when a health problem is referred to in the Connect Care CIS, it refers to a specific medical condition.

Problem List management (resolve, revise or promote) occurs at first encounter, care transitions or appropriate intervals.

Why does it matter?

The Problem List helps clinicians identify and manage patients’ medical problems at any point along the continuum of care. There are many CIS functions affected by Problem List content.

A patient’s health problems determine which ordering tools (Order Sets, SmartSets, Protocols, etc.), documentation aids (templates, flowsheets, forms, etc.), coordination aids (Express Lanes, Therapy Plans, etc.), decision supports (alerts, reminders, etc.), patient resources (handouts, questionnaires, etc.) and professional billing prompts are offered to speed workflows. Problem Lists are pulled into progress notes, consultations, discharge and transition summaries. Finally, patient registries, reporting tools, quality metrics and chronic disease management dashboards reference patient groupings defined by well-specified problems.

Messy Problem Lists impede workflows. Good Problem Lists provide the scaffolding for a clear, concise and impactful health record. They connect workflows within the CIS, and beyond through system interfaces and patient and provider portals.

Who is responsible?

All Prescribers share responsibility to update and manage Health Problems, especially those problems they have entered themselves. Problem List reconciliation (resolve, revise or promote) occurs at first encounter, care transitions, or appropriate intervals. Prescribers should update the Problem List in a way that befits their context (e.g., inpatient, outpatient), specialty, accountability and training. Connect Care does not micro-manage Problem List editing rights, instead expecting professionals to contribute responsibly while knowing that all entries and edits are tracked.

Minimum Use Expectations

Problem list management is a core clinical competency. Effective problem list management all ensures that charting is efficient and effective for all, and that no one prescriber group bears a disproportionate information burden within the Connect Care community. Accordingly, appropriate problem list management is included among prescriber minimum use norms.

Problem List review and validation (reconciliation) should be done at every care transition, including admission, transfer and discharge. It should also be done for every new outpatient encounter and periodically thereafter. Within encounters, the timely addition, revision and resolution of problems makes for faster documentation that more clearly shares clinically important information across the continuum of care.

Simply dictating a problem list into a note or letter does not meet a prescriber's problem list responsibilities. It is essential that the actual Problem List be revised to reflect current active problems. The list is then easily pulled in to documentation with one or more SmartTools.

Problem List Etiquette

One of the greatest challenges for teams is to jointly maintain a Problem List. Different Prescribers may have different notions about how specific a problem is characterized (e.g., “Chronic Obstructive Lung Disease” versus “Emphysema”), or whether a problem is active and relevant to ongoing care. Use of a digital health record does not absolve one from professional courtesy. When editing an existing health problem, or when consolidating a number of problems into one unifying diagnosis, it is important to help other Prescribers recognize changes and appreciate the reason(s) for changes.

How is it done?

Listed problems are active problems. A problem is active if it relates to the patient’s current health or treatment.

Inactive or past problems can be listed elsewhere in the chart, usually as part of the patient’s medical or surgical history. Goals, issues or targets can also be listed elsewhere (e.g., care plans).

Problem List Content

The Problem List is attached to the patient and is maintained by Prescribers. It is visible across the continuum of care (inpatient, outpatient, continuing, etc.). For a medical condition to be added to the Problem List, it should be:

  • Important: The problem is expected to impact care, whether in the shorter or longer term.

  • Relevant: The problem should be under active management, as may be reflected by diagnostic, therapeutic, rehabilitative, palliative or other interventions. Problems that no longer impact, or are impacted by, a patient’s current care should be resolved (removing them to an archive list) or entered or transferred to the Past Medical History or Past Surgical History.

  • Specific: The condition or diagnosis should be as specific as possible.

Problem List Views

The Problem List has a special organization in inpatient contexts, with sections for ‘Hospital’ and ‘Non-Hospital’ problems. It complements, not duplicates, the Problem List by highlighting issues specific to the current encounter. Problem List entries are reviewed at admission to mark those that are a focus of care during the admission. These hospital problems are reviewed at discharge to determine which are resolved and which need to remain in the enduring Problem List.

The Attending Prescriber is responsible for identifying or adding hospital-specific problems. Trainees and consultants may add problems or may communicate with the Attending Prescriber to update hospital problems.

The inpatient Problem List area (charting activity) may additionally include a section for ‘Multidisciplinary’ issues abstracted from care plans or other care coordination tools. These are distinct from health problems and are usually non-medical diagnoses managed by members of the patient’s care team. Listed issues may include symptoms (e.g., pain, nausea, etc.), nutritional status, functional status or goals pertinent to a specific encounter. Multidisciplinary issues are not edited by Prescribers, do not appear on the Problem List, and are not included in this Problem Documentation Norm.

Problem Histories

The Past Medical History and Past Surgical History are comprehensive listings of all significant past problems, procedures and surgeries. Although it is possible for problems to appear in both Past Medical or Surgical History and Problem Lists, such overlap should be kept to a minimum.

When reviewing or reconciling health problems, those that are not actively managed should be transferred to the Past Medical History. Resolved surgical problems or procedures should be transferred to the Past Surgical History. Past histories should be as concise as possible. They should not be cluttered with self-limited, temporary, inconsequential or remote issues lacking continued clinical importance.

Appropriate past medical history entries might include resolved chronic conditions, like obesity, but not temporary problems like conjunctivitis or intermittent symptoms like dry eyes.

Problem List Management

How is compliance measured?

Feedback about adherence to problem list minimum use norms is provided to prescribers through a "Connect Care Minimum Use Norms Feedback" display available in the Hyperspace "Dashboards" activity, available to all prescribers. There are separate metrics for inpatient and outpatient contexts.

Inpatient

Two measures are provided, one reflecting problem review at admission and the second reflecting problem list reconciliation at discharge.

  • Admission

    • Percentage of discharged inpatient encounters with an active hospital problem appearing on the problem list (problem list activity, problem-oriented charting activity, admission navigator, etc.) within 24 hours of placement of an admission order.

    • This metric provides some indication of whether problems are documented in conjunction with the preparation of a consultation or history and physical note required for admission to an inpatient facility.

    • The absolute value of the metric may be skewed in situations where the admitting prescriber is cross-covering a service on, for example, night call and the problem list review should have instead been allocated to the attending prescriber who reviews admission documentation.

    • Data Definition: Problem List Reconciliation at Admission

  • Discharge

    • Number of discharged inpatient encounters where the problem list (accessed in a variety of places, including the discharge navigator) is reviewed for resolved and/or ongoing problems within 48 hours of discharge.

    • The absolute value of the metric may be skewed in situations where the discharging prescriber is supervising a team or is otherwise different from the attending prescriber.

    • Data Definition: Problem List Reconciliation at Discharge

Outpatient

Two measures are provided:

  • Problem list marked as reviewed

  • Encounter diagnosis added to problem list

    • This metric calculates the percentage of outpatient encounters where the encounter diagnoses match entries on the patients' problem lists (an encounter diagnosis that is not reflected on the problem list suggests lack of problem list review and updating).

    • The absolute value of this metric may be skewed in situations where encounter diagnoses (e.g., "Physical Exam", "Health Maintenance", "Immunization") would not be appropriate for entry to the problem list and there has been no change in a patient's problems.

    • Data Definition: Add a Visit Diagnosis to the Problem List During Office Visits

Resources