x Facilitating continuity of care between patient visits
x Providing a comprehensive list of patient problems for use
in patient care and secondary data reporting
x Serving as a communication vehicle during transitions of
care and between care providers
Typical “out of scope” activities for problem lists include:
x Using problem lists as a source for billing data or revenue
x Forcing problem lists to substitute for a final diagnosis list
for discharge summaries
Identify who has ultimate responsibility for maintaining
the problem list and include this accountability in the approved
policy document. For example, the treating provider is responsible for reconciling the problem list at the beginning and end
of each episode of care. For primary care, the primary care provider is ultimately responsible. When specialty care is provided,
the specialist is responsible for updating the problem list to the
appropriate level of specificity. For inpatient care, the attending physician is responsible for problem list maintenance. For
organizations utilizing a multidisciplinary problem list, sections
may be used for separate disciplines. Examples include nursing,
physical or speech therapy, social workers, psychologists, and
other allied health professionals authorized to provide problem
Identify who is authorized to add, update, and resolve problems. For example, all independent licensed providers should
review and update the problem list at the end of each encounter.
Establish timeliness requirements for making problem list
entries and outline consequences for noncompliance.
Designate the types of entries to be included in the problem
list and any encoding systems used for representation. Determine the items to enter in problem lists. For example, ASTM International’s Standard Practice for Content and Structure of the
Electronic Health Record requires pathophysiological states,
potentially significant abnormal physical signs and laboratory
findings, disabilities, and unusual conditions be included in the
problem list. It also notes that providers may include social and
psychiatric problems, risk factors, allergies, and health alerts.
Organizations should describe the purpose of each item to include on a problem list.
Provide a detailed workflow for developing the list, updating it, and resolving problems, including the method of problem
list documentation entry into the health record.
Define procedures and accountability for maintaining and
updating the problem list clinical vocabulary or problem list
term subsets used by the EHR system.
Identify what role the patient plays in problem list development and maintenance.
Identify what (if any) barriers exist to ensuring problem list
integrity of the health record.
Describe the process for auditing problem lists for accuracy
Appendix A in the online version of this practice brief provides
a sample policy and procedure template.
Problem List Entry and Encoding
There are differing opinions about who should be authorized
to add entries to the problem list. Separate lists for physicians,
nurses, or other care providers (e.g., social workers, therapists,
pharmacists) may be a help or a hindrance depending on the
specific organization and its use of the problem list. More people adding entries contribute to more complex maintenance.
In addition to determining who may make entries to the problem list, organization must consider the method of entry they
will use. Some systems allow free text entries, while others use
an interface terminology. Interface terminology includes term
or phrase look-ups, known as pick lists, to populate the list. The
terms are usually linked or mapped to standardized code sets
(e.g., ICD or SNOMED C T ) to enable re-use of the data captured
for reporting or other secondary use.
Pick lists are efficient in situations where the number and
complexity of conditions are limited. Direct selection of codes
by clinicians requires knowledge of coding guidelines and con-
ventions to be accurate.
A facility may also use internal customized taxonomy to en-
code the problem list. This taxonomy should be mapped to ICD-
9-CM, ICD-10-CM, or SNOMED CT.
Provider organizations may also opt to use natural language
processing applications to parse free-form text and extract discrete data to populate problem list entries for confirmation.
The use of natural language processing saves time by presenting a list of potential entries that have already been linked to
SNOMED CT codes.
This approach can improve the accuracy and consistency of
the problem list, make updating easier, and increase compliance in the creation and updating of the problem list by clinicians.
It is also possible for clinicians to manually update and assign codes by accessing the code through pick lists or search
engines, but there are data integrity challenges inherent in this
approach. It should be noted there is ongoing debate on this
approach from practitioners and administrators. Many are reluctant to have computers making behind-the-scenes decisions
(mapping links to the code sets) and pre-filling the problem
list without their note of approval and validation that the code
stored accurately reflects the intended clinical facts.
The standardized terminology selected must represent complex clinical data accurately and in a computable form to efficiently retrieve and analyze the encoded data to drive automated decision support, reporting, and research functionality.
SNOMED CT’s hierarchically organized and interrelated predefined medical concepts support relevant query and retrieval
operations useful for clinical data representation.
The National Library of Medicine has released the Clinical
Observations Recording and Encoding, or CORE, a subset of
SNOMED CT. CORE facilitates the use of SNOMED CT for en-