Superior Health Information Management – Now and for the Future
Overview:
Maintaining a clean and accurate Problem List is part of the routine clinical
documentation process. Installation of the 2014 Certified EHR raises the
importance for a clean and accurate Problem List. The 2014 Certified EHR
introduces a new component called the Integrated Problem List (IPL) which
will replace the current Problem List. The IPL requires the use of SNOMED
CT
codes to document patient problems. A clean and accurate Problem
List will make the transition to the IPL less challenging for end-users. Here
are some guidelines and tips for the Problem List clean up.
Problem List Clean Up Guidelines
Review the Problem list for multiple entries of a diagnosis
Inappropriate entries include symptoms, procedures (i.e. colonoscopy),
administrative actions (i.e. Issue of Repeat Prescriptions), lab findings (i.e.
microscopic hematuria), and other non-diagnostic conditions (i.e. BMI >
40). Family history is an inappropriate entry on the Problem List and
should be entered in the Family History component.
Allergies should be entered in the Adverse Reaction component. Whether
a particular allergy should remain on the Problem List is based on local
policy ad clinical judgment.
Resolved problems include those that are episodic or acute in nature (i.e.
UTI, bronchitis, ankle sprain, etc.)
All diagnoses on the Problem List need to be associated with the proper
ICD 9 code. A .9999 code indicates the diagnosis has not been coded.
Problem List Clean Up Plan
Recommend MU and EHR team members discuss the strategy to clean
up the Problem List. Reassess workflow processes to identify efficient
methods to clean up the Problem List prior to installation of the 2014
Certified EHR system.
The reality is that a Problem List that has not been maintained will require
a team approach for cleanup. This is not a “One Man Job”. Problem List
cleanup can be a part of the current workflow process:
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Clinic Nurses: update the Problem List when reviewing the patient
charts for the next day or when entering standing orders for lab prior
to selecting the clinical indication.
∗
Nurse Case Managers/Public Health Nurses: update the Problem
List when reviewing the patient chart for follow up.
∗
Clinical Dietitians: update the Problem List when reviewing the
patient chart prior to selecting the medical diagnoses associated
with the POV.
∗
Pharmacists: update the Problem List when refilling medications
prior to selecting the clinical indication.
∗
Physicians and Mid-Level Providers: review and update the problem
list when entering the POV, ordering medications and labs prior to
selecting the clinical indication.
Focus on cleaning up active problems.
Data entry/coding staff can generate a list of un-coded diagnoses that are
on the Problem List. Do not ask coders to assign codes to un-coded
diagnoses until the clinical staff has removed redundant and inappropriate
entries.
Cleaning up the Problem List is a clinical staff responsibility.
This includes physicians, nurse practitioners, physician assistants,
Problem List Clean Up Examples– The Good, The Bad and The Ugly:
1. Considerations: In some situations cervicalgia may be considered an ongoing
problem. Review chart to determine the status.
1. Considerations: Pay attention to diagnoses with closely related ICD codes. This
example shows a diagnosis for hypertensive heart disease without heart failure
(402.90) last modified in 1999. A diagnosis was added for mild congestive heart failure (428.0) in 2013. Select Problem #9 and click the button to change the status to “Inactive”.
1. Remove Redundant Entries: Click the button and select “Duplicate Entry” as the
reason for deletion. Delete the most recent entry if notes or date of dx are not entered.
2. Inactivate Resolved Problems: May need to review chart to determine if this is a
chronic problem. Click the button and change status to “Inactive” if resolved.
3. Remove Inappropriate Entries: Click the button, select “Other” and enter
“Inappropriate Entry – entered in Historical Services” in the free text field as the reason for deletion. Enter procedure in the Historical Services component.
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1. Un-coded Diagnoses: Assign an ICD – 9 code for each diagnosis. Determine if diagnosis is an ongoing problem (i.e. eczematous dermatitis). Inactivate resolved problem if indicated. Click the button and change status to “Inactive”.
2. Inactivate Resolved Problems: May need to review chart to determine if this is a
chronic problem. Click the button and change status to “Inactive”.
3. Remove Allergies: Click the button, select “Other” and enter “Inappropriate Entry
– entered in Adverse Reactions” as the reason for deletion. Enter allergies in the Adverse Reaction component.
4. Remove Inappropriate Entries: Click the button and select “Entered In Error”.
1. Remove Inappropriate Entries: Click the button and select “Entered in Error” as
the reason for deletion.
2. Inactivate Resolved Problems: Pay attention to diagnoses with closely related ICD
codes. Review the chart to determine the diagnosis and edit as appropriate.
3. Remove Allergies: Click the button, select “Other” and enter “Entered in Adverse
Reactions” as the reason for deletion. Enter in the Adverse Reaction component.
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1. Un-coded Diagnoses: Assign an ICD – 9 code for each diagnosis. Determine if diagnosis is an ongoing problem. Inactivate resolved problem if indicated. Click the
button and change status to “Inactive”.
2. Redundant Entries*: Click the button and select “Duplicate Entry” as the reason
for deletion. Delete the most recent entry if notes or date of dx are not entered. Add the procedures to Historical Services.
3. Consideration: Address diagnoses related to a personal history. Click the button
and change status to “Personal History”. This will change the status to “Inactive” and will display “Personal History” in the Class column. Add Nephrectomy to Historical Services.
4. Remove Inappropriate Entries*: Click the button, select “Other” and enter
“Inappropriate Entry – entered in Family History” as the reason for deletion. Enter in Family History component.
5. Considerations: Some diagnoses require clinical judgment to determine if the
diagnosis should remain on the Problem List. This will need to be determined at the local site as to which diagnoses should be retained. Some examples are: ASA Prophylaxis, Tobacco Use Disorder, Alcohol Abuse, etc.
6. Remove Inappropriate Entries: Click the button and select “Entered in Error” as
the reason for deletion. Look in Historical Diagnosis to determine if a diagnosis for Obesity was entered by a provider. Obesity can be then be added to the Problem List. This can be done by clinical staff members that cannot make a diagnosis.
*NOTE: This example includes inactive problems. It is recommended that the focus be
cleaning up active problems. Although, this demonstrates the need to inactivate historical diagnoses and add (or make sure) family history is entered in the Family History component.
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1. Remove Inappropriate Entries: Click the button and select “Entered in Error” as the reason for deletion.
2. Remove Inappropriate Entries: Click the button and select “Other” and enter
“Entered in Historical Services” in the free text field as the reason for deletion. Enter procedures in the Historical Services component.
3. Un-coded Diagnoses: Assign an ICD – 9 code for each diagnosis.
4. Remove Allergies: Click the button, select “Other” and enter “Entered in Adverse
Reactions” in the free text field as the reason for deletion. Enter in the Adverse Reaction component.
5. Inactivate Resolved Problems: Click the button and change status to “Inactive”.
Add Nephrectomy to Historical Services.
6. Redundant Entries: Click the button and select “Duplicate Entry” as the reason
for deletion. Delete the most recent entry if notes or date of dx are not entered.
7. Considerations: Pay attention to diagnoses with closely related ICD codes.Review
chart to update as appropriate.
8. Remove Inappropriate Entries: Click the button and select “Entered in Error” as
the reason for deletion.
9. Redundant Entries: Click the button and select “Duplicate Entry” as the reason
for deletion. Delete the most recent entry if notes or date of dx are not entered.
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Problem List Clean Up Tips
• Select “Active Only” to display problems with an Active Status.
• Use the sort feature on the ICD column to sort problems by the ICD code. Double click on the ICD header to sort. Problems with duplicate or similar ICD 9 codes will be displayed together.
• Pay attention to diagnoses with closely related ICD codes. Working with coding staff to assist with this.
• Some diagnoses require clinical judgment to determine if the diagnosis should remain on the Problem List. This will need to be determined at the local site as to which diagnoses should be retained. Some examples are: ASA Prophylaxis, Tobacco Use Disorder, Alcohol Abuse, etc.
• Address diagnoses related to a personal history. Click the button and change status to “Personal History”. This will change the status to “Inactive” and will display “Personal History” in the Class column. Add Nephrectomy to Historical Services.
• Review the diagnoses listed in the Historical Diagnosis panel to determine ongoing problems.
• Identify ongoing problems that have not been added to Problem List.
• Avoid spending a significant amount of time reviewing charts.
• Collaborate with clinic staff to determine local policies for decision making with
diagnoses displayed on the Problem List that may be considered episodic or acute in nature (i.e. headaches/cephalgia, allergic rhinitis, etc.)
