policies that establish processes for updating and/or removing diagnoses resulting from a provider’s response to a CDI or
coding query. Specifically, they need to address whether editing is permissible by roles other than independent licensed
professionals who are able to make medical diagnoses; if so,
those roles should be specified in the organization’s privileging policies and their responsibilities in terms of authorship
should be clearly stated. See the sidebar on page 45 for more
on developing organizational policies.
CDI and coding professionals do not typically modify a provider’s documentation in the health record. Some organizations require the provider to update their documentation in
the health record in response to a query, while other organizations include the query as part of the legal health record to
update a provider’s documentation. Ideal practice is to have a
provider of record update the problem list. Unfortunately, the
effectiveness of using a query to amend the provider’s documentation will be limited within the confines of a problem
list so organizations may decide to allow CDI and/or coding
professionals to update and/or remove problem list diagnoses when supported by provider documentation in response
to a query. If an organization grants such permissions to non-practitioners, authorship of such entries should be clearly
identified and closely audited for compliant practice. Health
information management (HIM) and CDI professionals play
an important role in helping to maintain the problem list, but
review and oversight by a provider is also required, as inaccurate or outdated problem list entries can impact patient safety.
Therefore, it is important for each organization to have medical staff bylaws that clearly address provider responsibilities
in regard to reviewing and updating all documentation in the
health record, including the problem list.
While each provider rendering patient care should be responsible for updating the problem list during each encounter,
the provider’s ability to make accurate revisions to an existing problem list may vary according to their familiarity with
the patient and area of practice. Additionally, providers may
not have access to all relevant diagnoses due to challenges related to the current state of interoperability. How problem lists
are updated may also depend on the capabilities of the specific EHR platform. 6 Managing the problem list can be labor-intensive which means this is often inconsistently performed,
which may lead to inaccurate, incomplete, duplicative, and
outdated lists. 7
Hospital and practice scores in the Quality Payment Program’s
“Promoting Interoperability” performance category require
healthcare organizations to import and reconcile electronic
summary of care documents, including the problem list. Organizations need to develop policies, procedures, and work flows
that optimize the reconciliation process.
Organizations that classify the problem list as clinical docu-
Regulatory Requirements and Compliance
mentation need to create an ongoing standardized reconcilia-
tion process to synchronize the problem list among providers
and across settings. Such a reconciliation process with the use
of reporting capabilities may allow a designated individual
(example: HIM/CDI professional) to use the Strengths, Weak-
nesses, Opportunities, and Threats (SWOT) approach to make
recommendations to the primary care provider:
1. Identifypatients who wereseenbyaproviderinthehealth-
care system at least twice during the past 12 months. Or-
ganizations should establish the level of frequency for this
step (i.e., monthly, quarterly, etc.).
2. Compare each diagnosis included on each problem list to
documentation available in the applicable health record
to confirm, suggest an update, or suggest removal of an
3. Create a master problem list that includes the recommen-
dations across all reviewed encounters to identify oppor-
tunities to consolidate similar diagnoses and remove con-
ditions integral to other diagnoses.
4. Forward the recommendation to the designated provider
of record (i.e., provider, nurse practitioner/physician as-
sistant (NP/PA), etc.) for review.
5. Once the master problem list has been approved by the
designated provider of record, update the problem list in
the patient’s longitudinal record of care according to or-
The following offers a summary of problem list regulatory requirements and other compliance initiatives.
The Joint Commission
The Joint Commission’s (TJC’s) Hospital Accreditation Standard
(RC.02.01.07) requires a summary list for each patient who receives continuing ambulatory care services in the health record.
This summary list is required to be initiated by the third visit.
Even though a summary list is not the same as the problem list,
some organizations view both lists to be the same. The summary
list may include medical diagnoses, operative and invasive procedures, and any current medications. These content elements
potentially require additional provider consideration or intervention. TJC standard requires providers to update a patient’s
summary list whenever there is a change in diagnosis, medications, and/or allergies to medications and whenever a procedure is performed. TJC also requires the patient summary list
to be readily available to other providers so that the appropriate
treatment and care can be provided.
ASTM International’s Standard Practice for Content and Structure of the Electronic Health Record (E1384-07) indicates that
the problem list should contain all past and current diagnoses,
pathophysiological states, potentially significant abnormal
physical signs and laboratory findings, disabilities, and unusual conditions. The standard also notes that the problem list
should be amended as more precise definitions of problems