Add a Problem to a Patient Record
The Problems page holds a record of problems, conditions, and past medical history for the patient. Most often, problems are added in the clinical note, however previous problems or active problems that are unrelated to the patient's visit can be added on the Problems page. When adding a problem or condition, you can also enter an associated diagnosis. If the patient does not have any problems, mark the "No known problems" box.
A problem can be added to the Problems page in a patient's record based on various scenarios:
- A problem the patient had in the past that has resolved (designated as Inactive)
- A problem that was diagnosed some time ago for which the patient is still being treated (designated as Active)
Navigate to Patient Record / Problems
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Add Problem to Patient Record
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Add a Problem Using the ICD-10 Problem Field
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Add a Problem Using the ICD Browser Click Browse to open the ICD Browser window and search for a specific codes, add a code to your favorites, switch between ICD-9 and ICD-10, choose a code from your saved favorites, or select a previous Dx code from the patient's record.
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Enter problem by searching Problem/Issue keyword(s): Add a problem to a note by searching for the clinical name or code of the problem/issue. This field provides more general search results and specifically targets clinical terminology and SNOMED codes.
Note: A problem not in the list can be manually entered, however, selecting from the list of results whenever possible is recommended. The results list is codified to help with reporting and clinical decision support. |
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Tips
Use these examples to help you choose the appropriate options as you record the patient's problems:
- An old, resolved condition that you want to add to medical history but not to the active Problems List (for example, the patient had thyroid cancer and has since had all of the thyroid removed): Choose Inactive and Resolved. In this case, the condition is recorded in the inactive Problems List and in Past Medical History.
- An old condition that is ongoing for which you want to capture historical data and also add to the active Problems List (for example, the patient was diagnosed with hypertension 20 years ago and is still being treated for it): Choose Active and Chronic. In this case, the condition is recorded in the active Problems List, Past Medical History and in the currently opened encounter note (if you are adding the problem to an encounter note).
- A new condition that needs to be captured as both an active problem and in the Past Medical History (for example, the patient is being seen for newly diagnosed diabetes): Choose Active and Chronic. In this case, the condition is recorded in the active Problems List, Past Medical History, and in the currently opened encounter note (if you are adding the problem to an encounter note.
- A new condition needs to be captured within the current encounter but not in the Past Medical History (for example, a patient has a cold or the flu): Choose Active and Acute. In this case, the condition is recorded in the active Problems List and in the currently opened encounter note (if you are adding the problem to an encounter note).