Patient Chart Problem List

This article will cover

Active Problems | Inactive & Resolved Problems | Adding Problems | Audit Log |Print List

The problems list provides users with both flexibility and clear visibility into their patients' conditions. It allows them to easily add, edit, or remove problems, ensuring they have up-to-date, comprehensive information on all active health concerns.

Active Problems

• Displays the number of active problems beside the header name.
• No known active problems check box.
• Ability to reorder dragging and moving up/down problem list.
• Pagination tracker at the bottom of the problem table.
• Problem - problem description, ICD-10, CPT, and SNOMED code.
• Notes - additional documentation associated with the problem.
• Onset Date - the date when the problem started.
• Action - edit or choose the ellipsis drop-down for additional options.
• Edit () - edit the problem status ( active, inactive, or resolved), onset date, associated appointment, and notes.  Users can cancel or save problem updates.
• Ellipsis () - click to view the dropdown for additional actions.
• Check Problem Info - redirects to the National Library of Medicine (Medline Plus Connect) website to review information about the problem.
• Download HL7 2.5.I  File - option to download the file.
• Delete Problem -  a pop-up window will appear to confirm before deleting the problem.  A confirmation window will appear once the problem is deleted.

Inactive & Resolved Problems

• Displays the number of inactive and resolved problems beside the header name.
• Problem - problem description, ICD-10, and SNOMED code.
• Notes - additional documentation associated with the problem.
• Onset Date - the date when the problem started.
• Abatement Date - alleviation of the problem or when it was resolved.
• Action - reactive problem or click more to view the dropdown for additional actions.
• View Problem Notes - view additional documentation associated with the problem.
• Check Problem Info - redirects to the National Library of Medicine (Medline Plus Connect) website to review information about the problem.
• Download HL7 2.5.I  File - option to download the file.
• Delete Problem -  a pop-up window will appear to confirm before deleting the problem.  A confirmation window will appear once the problem is deleted.

Adding Problems

• Red asterisk = required field.
• Problem search field - ICD-10 and SNOMED code displays once the problem populates.
• Status - select if the problem is active, inactive, or resolved.
• Onset date - the date when the problem started.
• Appointment - date of service the problem is associated with.
• Notes - additional documentation associated with the problem.
• Cancel, Save and Add Another or Add Problem.

Frequently used problems

Duplicate Checking

The duplicate checking feature alerts users if they try to add a duplicate problem . Users can either cancel the action or update the existing entry with new information, overwriting the old data. The system checks both active and inactive tabs for duplicates. If a problem already exists on the inactive tab, users are notified and can choose to reactivate the old problem or proceed with adding the new one based on the data entered.

External Records

When problems from external sources require reconciliation, the system notifies the user through the clinical dashboard, prompting them to review and take action on these issues within the problem list.

Audit Logs

• Action - tracks when the problem was created, edited, or deleted.
• User - the name of the individual that made the change  to the problem. 
• Date - date of action.
• Log - provides activity documentation for the problem.

Print List

• Print active or full problem list.

Click the link to watch a tutorial about Problems List.