7. Problem list entries should be linked to a corresponding
code from a controlled structured nomenclature for consistency.
8. Problem list software should provide for audit trails so
changes made with date and time stamps are available for
review.
Well-designed problem lists provide important information
for patient care and support meaningful use requirements and
health information exchange. There are many approaches to a
well-designed problem list. The key is to define clear policies
and procedures that support the organization’s objectives in using the information contained in a problem list. ¢
Notes
1. AHIMA. Pocket Glossary of Health Information Management and Technology, Third Edition. Chicago, IL: AHIMA,
2011.
2. ASTM International. “ASTM E1384—07 Standard Practice
for Content and Structure of the Electronic Health Record
(EHR).” www.astm.org/Standards/E1384.htm.
3. Health Level Seven International EHR Technical Committee. “Electronic Health Record–System Functional Model,
Release 1. February 2007. Chapter Three: Direct Care
Functions.” www.hl7.org/ehr.
4. Accreditation Association for Ambulatory Health Care.
“Clinical Records and Health Information.” In 2011 Accreditation Handbook for Ambulatory Healthcare. Skokie,
IL: Accreditation Association for Ambulatory Health Care,
2011.
5. Healthcare Information Technology Standards Panel.
www.hitsp.org.
6. Department of Health and Human Services, Centers for
Medicare and Medicaid Services. “Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule.” July 28, 2010. http://edocket.access.gpo.
gov/2010/pdf/2010-17207.pdf.
7. Ibid.
8. Healthcare Information Technology Standards Panel.
“Comparison of CCR/CCD and CDA Documents.” December 2009. http://publicaa.ansi.org/sites/apdl/hitspad-
min/Matrices/HITSP_09_N_451.pdf.
9. National Library of Medicine. “The CORE Problem List
Subset of SNOMED CT.” www.nlm.nih.gov/research/
umls/Snomed/ core_subset.html.
Resources
AHIMA. “Stage 1 Meaningful Use Objectives, Measures, and
Corresponding Initial Set of Standards, Implementation
Specifications, and Certification Criteria.” 2010. Available
in the AHIMA Body of Knowledge at www.ahima.org.
AHIMA. “Best Practices for Problem Lists in an EHR.” Journal
of AHIMA 79, no. 1 (Jan. 2008): 73–77.
Bayegan, Elisabeth, and Samson Tu. “The Helpful Patient Re-
cord System: Problem Oriented and Knowledge Based.”
AMIA 2002 Annual Symposium Proceedings. www.ncbi.
nlm.nih.gov/pmc/articles/PMC2244287/pdf/procami-
asymp00001-0077.pdf.
Campbell, James R. “Strategies for Problem List Implementation in a Complex Clinical Enterprise.” AMIA Annual Symposium Proceedings 1998. www.ncbi.nlm.nih.gov/pmc/ar-
ticles/PMC2232208/pdf/procamiasymp00005-0321.pdf.
Cook, Jane, et al. “Universal Adapters: Terminology Standards
Enable Meaningful Data Exchange.” Journal of AHIMA 80,
no. 1 (Jan. 2009): 36–40.
Garvin, Jennifer H., et al. “Omaha System: Coded Data That
Describe Patient Care.” Journal of AHIMA 79, no. 3 (Mar.
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Holmes, Casey. “The Problem List beyond Meaningful Use:
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82, no. 2 (Feb. 2011): 30–33.
Holmes, Casey. “The Problem List beyond Meaningful Use:
Part 2: Fixing the Problem List.” Journal of AHIMA 82, no. 3
(Mar. 2011): 32–35.
Meystre, Stephane, and Peter Haug. “Improving the Sensitivity
of the Problem List in an Intensive Care Unit by Using
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PMC1839473.
Song, Fei, and R. William Soukoreff. “A Cognitive Model for the
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and Biotechnology. www.dynamicnetservices.com/~will/
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Song, Fei, and R. William Soukoreff. “Graphical Interface
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Weed, Lawrence L. “Medical Records That Guide and Teach.”
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Zaccagnini, Davide. “The Problem with Problem Lists.”
Health Management Technology, November 2010. www.
healthmgttech.com/index.php/solutions/electronic-medical-records/ the-problem-with-problem-lists.html.
Appendix
An appendix is available in the online version of this practice
brief in the AHIMA body of Knowledge at www.ahima.org:
x Appendix A: Sample Policy and Procedure Template
Prepared By
Beth Acker, RHIA
June Bronnert, RHIA, CCS, CCS-P
Teresa Brown, RHIT, Six Sigma Black
Jill S. Clark, MBA, RHIA
Betty Dunagan, RHIA
Tracy Elmer, RHIA
Suzanne Goodell, MBA, RHIA
