Add a Problem to a Patient Record

Last updated

10:52, 10 Apr 2017
Save as PDF

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 Enter the first 2–3 letters of the patient's name in the top search box. Click to select the patient from the auto-populated results. The patient's record opens to the Face Sheet. Click Problems in the left menu. The patient's Active Problems List displays.
Add Problem to Patient Record Click +Problem on the right side of the page. The Add to Problem List window opens. By default, the new problem is set to display as Active. Click Inactive to add the problem to the Inactive list. Add the problems one of three ways: ICD-10 Problem (Recommended): Search your saved favorite codes or enter general diagnosis keyword(s) or a code to search for a specific code. ICD Browser: Search for a specific code, switch between ICD-9 and ICD-10, choose from your saved coding favorites, or select a previous Dx code from the patient's record. Problem/Issue: Search for a problem by entering clinical (SNOMED) terminology. Click to select if the problem Type is Acute or Chronic. will auto-set to Acute or Chronic based on the problem that is entered. Click to change the Type, if desired. Enter the problem Start Date and End Date (for Acute problems), if known. Enter any optional notes about the problem in the Comments box. Click Save to add the problem to the patient record.
Add a Problem Using the ICD-10 Problem Field It's best practice to use the ICD-10 Problem field as a starting point when adding a problem. Click in the ICD-10 Problem field to view and select from a list of saved coding favorites. Note: Favorite ICD-9 codes are also available and will map to ICD-10 if selected. Search for a code by typing the diagnosis description or code in the ICD-10 Problem field and selecting from the list of results. When More > displays, click to open more defined results and find the most accurate code. Once an ICD-10 code is entered, the appropriate problem auto-populates in the Problem/Issue field, or a list displays if more than one option is available. The system auto-populates the appropriate ICD-9 code (if available) after an ICD-10 code is entered. Note: The ICD-9 field is optional and can be left blank.
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. Click Browse in the Add Problem to List window. The ICD Browser window opens. Favorites: Provides the list of the codes you have saved as favorites. Patient Dxs: Displays the patient's previous diagnosis. Search: Search by code or description. For example, enter a problem in the search field and click Search. Note that clicking x clears the entry for a new search. Enter a word or code and click Search. ICD-10 codes display by default. Click the drop-down to switch between ICD-9 and ICD-10 codes, or click 9 -> 10 to view code conversion. Note: an ICD-10 code must be entered to add a new Problem. Click the triangle to refine results and find a more specific code. Click a code in the list to select it. The selected code displays highlighted in blue. Hover over a code and click the star to add it to your coding favorites. Click Done to add the selected code. The Add to Problem List window re-opens and the selected code displays.
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. Begin entering the name of the problem/issue and select it from the results when displayed. A list of the most appropriate ICD-10 codes displays below the ICD-10 Problem box. Click to select the right ICD-10 code. The system will auto-populate the appropriate ICD-9 code, if available. 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.

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).