legal health record, while system-generated information based
on the abstraction from other parts of the EHR, which may be
used for administrative purposes, may have other legal implications. A problem list that is considered part of the legal health
record must be produced upon request by a patient and/or third
party during a lawsuit.
The following are some contemporary issues with the problem
list that should be considered.
Governance, Authorship, and Ownership
Patients frequently receive care from multiple providers from
different specialties that may use disparate EHR software platforms. In this situation, it is common for a patient’s problem list
to vary by setting, which undermines the purpose of the problem list—a central repository of active and chronic conditions
for the patient as a whole. Ideally, problem lists and updates
would be accessible to all providers across the patient’s spectrum of care, but in most settings problem lists are maintained
independently in each organization’s EHR.
The problem list should be maintained and updated every
time the patient is seen by a provider so that the continuity of
care is maintained. A patient might not see the same provider,
and therefore it is impossible to have continuity of care when
a patient’s appendicitis remains in the problem list two years
later because there is no formalized process in place to review
and address outdated entries. It is each provider’s responsibility to go through the problem list and validate the status
of each condition during each visit/encounter. Best practice
would be for all active/current diagnoses to be reviewed with
the patient during the encounter. For example, this could be
done prior to obtaining and/or reviewing the patient’s history to update the status of conditions that resolved between
Organizations should develop a policy that outlines who
can make entries into the problem list and that determines
if the entries are to be considered as clinical documentation
to guide CDI and coding practices. Organizations that allow
the problem list to be used as clinical documentation need
Developing Organizational Policies
THESE LISTS ARE adapted from the AHIMA Thought Leadership Series white paper “Problem Lists in Health Records: Ownership, Standardization, and Accountability.”
ORGANIZATIONAL POLICY SHOULD BE BASED ON:
Defining the role of the problem list as a tool to support patient care
Defining the philosophy about patient involvement in their care
Workflow efficiency and organizational requirements
ORGANIZATIONAL POLICY MUST BE CLEAR ABOUT THE FOLLOWING:
Who may add, modify (update), and delete/demote/retire a problem from the problem list?
Who has access and retrieval privileges of the problem list?
Safeguards for authentication, security, and reliability.
Establish a mechanism for “provenance” of the problem list, such as a process that stores the identity of the individual
who made or modified a problem list entry, as well as a date and time stamp.
Changes to the problem list. No one should be authorized to delete/demote/retire (e.g., resolved date) problems from
this list without following the standard process for updating, correcting, or amending the health record.
When updating takes place (items added, archived, or marked as resolved).
If applicable, linkage to source documents should be permitted.
Items affecting patient safety (e.g., fall risk) should always be prominently displayed. Ideally, these items appear at the
top of any problem list for emphasis.
The process for creating and using specific “views” of the list to improve functional utility for problem entry, user access, and maintenance efficiency.
The process for resolving disagreements between providers concerning problem list content.
The process for accommodating differing views between patient and provider on the list.
The role of the clinician in this person’s care.
Where the list is viewed and stored.
How and when the list is maintained for accuracy and completeness.
Tools or vocabulary sources (if any) required to support interoperability and information retrieval.
Standards (if any) that govern the use or content of problem lists literacy level.
Policies for reconciling problem lists received from other organizations in electronic or other form.
Source: Bice, Michael O. et al. “Problem Lists in Health Records: Ownership, Standardization, and Accountability.” 2012. http://bok.ahima.org/