Problem List Management

A list of active health conditions (“Problem List”) appears in all charts in all contexts. Problem List entries can be signs, symptoms, presentations, disorders or diseases that have an impact on, or could be impacted by, a patient’s current care. This section focuses on problem management skills consistent with Connect Care Problem List Norms.

Definition - Health Problems

An health issue, condition or disease is an active health problem if:

The "principal problem" is the main reason for presentation ("chief complaint"). At admission, it is the "admitting diagnosis". It will likely become more specific by discharge and becomes the "discharge diagnosis". See Managing Problems below for more detail.

Problem vs. History

A patient's Problem List is not the only place where a health condition can be documented. The "Medical History", "Surgical History" and "Family History" chart sections also hold information about health conditions. Indeed, good problem list management is often about knowing when to move problems back and forth between the Problem List and Medical History. 

When should conditions be moved or added to the Problem List and when they should be resolved or moved to the Medical History?