problems, psychiatric problems, risk factors, allergies, reactions to
drugs or foods, behavioral problems, or other health alerts may be
included. 2
The standard also notes that the problem list should be
amended as more precise definitions of problems become
available. Controlled vocabulary for problem lists may be contained in a problem list directory master table.
Of note in this standard is the reference to past diagnoses and
social care factors. Some problem lists limit entries to those factors requiring current action or consideration.
Health Level Seven International
Designated by the International Organization for Standardization as a standard, Health Level Seven International’s Electronic
Health Record System Functional Model (EHR-S FM) provides
additional guidance for EHR content. The model states, “A problem list may include, but is not limited to chronic conditions,
diagnoses, or symptoms, functional limitations, visit or stay-specific conditions, diagnoses, or symptoms.” 3
The model recognizes that problem lists are dynamic and must
be managed over time and may in fact be maintained over the
life of an individual. For this reason the record system should
support documentation of historical information and track the
changing character of problems and their priority.
The model outlines the following functional requirements related to problem lists:
1. The system SHALL capture, display, and report all active
problems associated with the patient.
2. The system SHALL capture, display, and report a history
of all problems associated with a patient.
3. The system SHALL provide the ability to capture the onset date of problem.
4. The system SHALL provide the ability to capture the
source, date, and time of all updates to the problem list.
5. The system SHALL provide the ability to deactivate a
problem.
6. The system SHOULD provide the ability to manually or-der/sort the problem list.
7. The system SHOULD provide the ability to capture the
chronicity (chronic, acute/self-limiting, etc.) of a problem.
8. The system MAY provide the ability to re-activate a previously deactivated problem.
9. The system MAY provide the ability to associate encounters, orders, medications, notes with one or more problems.
The source for problem list updates or resolutions—that is, the
authentication and identification for all health record entries—
must be recorded. In order to maintain data integrity and fulfill legal requirements all pertinent dates must be captured and
stored, including date and/or time noted or diagnosed, dates
and/or time of any changes in problem specification or prioriti-
zation, and the date/time of resolution. Automated time stamps
may be used where appropriate.
Accreditation Association for Ambulatory Health Care
The Accreditation Association for Ambulatory Health Care’s
standard is used by outpatient facilities providing ambulatory
health services. The standard indicates if a patient has had multiple visits/admissions or if the clinical record is complex and
lengthy, a summary of past and current diagnoses or problems,
including past procedures, is documented in the patient’s record to facilitate the continuity of care. 4
The standard requires that the presence or absence of allergies
and untoward reactions to drugs and materials be recorded in
a prominent and consistent location in all clinical records. This
information must be verified at each patient encounter and updated whenever new allergies or sensitivities are identified.
Healthcare Information Technology Standards Panel
The Healthcare Information Technology Standards Panel convened stakeholder meetings between 2005 and 2010 to advance
interoperability and EHR adoption. An informative set of harmonized work products formed a solid foundation for future
standards development, such as adopting SNOMED CT as the
standard vocabulary for documenting patient problems with
links to ICD-9-CM to support data sharing and interoperability. 5
Since that time the HIPAA transactions and code sets have
been updated to require the use of ICD-10-CM/PCS by October
1, 2013.
Alignment with meaningful use requirements provides for use
of ICD or SNOMED CT for problem list encoding with migration to SNOMED CT completed by 2015. There are distinct differences in the use of a classification (e.g., ICD) and a reference
terminology (SNOMED CT) that must be taken into account.
Both provide the ability for information retrieval and consistency of record entries facilitated by a controlled vocabulary. The
National Library of Medicine has developed a designated subset
of SNOMED CT specifically for use in problem lists.
Meaningful Use Program
The American Recovery and Reinvestment Act of 2009 established the meaningful use incentive program, which encourages nationwide adoption of EHRs that improve patient care. The
program requires the problem list contain all past and existing
diagnoses, pathophysiological states, potentially significant abnormal physical signs and laboratory findings, disabilities, and
unusual conditions. 6
Reporting requirements for the problem list for the stage 1
meaningful use requirements state the provider must “maintain
an up to date problem list of current and active diagnoses based
on ICD-9-CM or SNOMED-CT for 80% of patients, and 80% of
all patients have to have at least one coded problem as opposed
to their entire problem list coded.” The provider is required to
place all patients on a common dictionary through coding.
