Review the Problem list for multiple entries of a diagnosis

Transcription

1 Superior Health Information Management Now and for the Future Overview: Maintaining a clean and accurate Problem List is part of the routine clinical documentation process. Installation of the 04 Certified EHR raises the importance for a clean and accurate Problem List. The 04 Certified EHR introduces a new component called the Integrated Problem List (IPL) which will replace the current Problem List. The IPL requires the use of SNOMED CT codes to document patient problems. A clean and accurate Problem List will make the transition to the IPL less challenging for end-users. Here are some guidelines and tips for the Problem List clean up. Problem List Clean Up Guidelines Review the Problem list for multiple entries of a diagnosis Inappropriate entries include symptoms, procedures (i.e. colonoscopy), administrative actions (i.e. Issue of Repeat Prescriptions), lab findings (i.e. microscopic hematuria), and other non-diagnostic conditions (i.e. BMI > 40). Family history is an inappropriate entry on the Problem List and should be entered in the Family History component. Allergies should be entered in the Adverse Reaction component. Whether a particular allergy should remain on the Problem List is based on local policy ad clinical judgment. Resolved problems include those that are episodic or acute in nature (i.e. UTI, bronchitis, ankle sprain, etc.) All diagnoses on the Problem List need to be associated with the proper ICD 9 code. A.9999 code indicates the diagnosis has not been coded.

2 Cleaning up the Problem List is a clinical staff responsibility. This includes physicians, nurse practitioners, physician assistants, pharmacists, nurses and clinical dietitians. Problem List Clean Up Plan Recommend MU and EHR team members discuss the strategy to clean up the Problem List. Reassess workflow processes to identify efficient methods to clean up the Problem List prior to installation of the 04 Certified EHR system. The reality is that a Problem List that has not been maintained will require a team approach for cleanup. This is not a One Man Job. Problem List cleanup can be a part of the current workflow process: Clinic Nurses: update the Problem List when reviewing the patient charts for the next day or when entering standing orders for lab prior to selecting the clinical indication. Nurse Case Managers/Public Health Nurses: update the Problem List when reviewing the patient chart for follow up. Clinical Dietitians: update the Problem List when reviewing the patient chart prior to selecting the medical diagnoses associated with the POV. Pharmacists: update the Problem List when refilling medications prior to selecting the clinical indication. Physicians and Mid-Level Providers: review and update the problem list when entering the POV, ordering medications and labs prior to selecting the clinical indication. Focus on cleaning up active problems. Data entry/coding staff can generate a list of un-coded diagnoses that are on the Problem List. Do not ask coders to assign codes to un-coded diagnoses until the clinical staff has removed redundant and inappropriate entries.

3 Problem List Clean Up Examples The Good, The Bad and The Ugly:. Considerations: In some situations cervicalgia may be considered an ongoing problem. Review chart to determine the status.. Considerations: Pay attention to diagnoses with closely related ICD codes. This example shows a diagnosis for hypertensive heart disease without heart failure (40.90) last modified in 999. A diagnosis was added for mild congestive heart failure (48.0) in 0. Select Problem #9 and click the button to change the status to Inactive.. Remove Redundant Entries: Click the button and select Duplicate Entry as the reason for deletion. Delete the most recent entry if notes or date of dx are not entered.. Inactivate Resolved Problems: May need to review chart to determine if this is a chronic problem. Click the button and change status to Inactive if resolved.. Remove Inappropriate Entries: Click the button, select Other and enter Inappropriate Entry entered in Historical Services in the free text field as the reason for deletion. Enter procedure in the Historical Services component.

4 4. Un-coded Diagnoses: Assign an ICD 9 code for each diagnosis. Determine if diagnosis is an ongoing problem (i.e. eczematous dermatitis). Inactivate resolved problem if indicated. Click the button and change status to Inactive.. Inactivate Resolved Problems: May need to review chart to determine if this is a chronic problem. Click the button and change status to Inactive.. Remove Allergies: Click the button, select Other and enter Inappropriate Entry entered in Adverse Reactions as the reason for deletion. Enter allergies in the Adverse Reaction component. 4. Remove Inappropriate Entries: Click the button and select Entered In Error.. Remove Inappropriate Entries: Click the button and select Entered in Error as the reason for deletion.. Inactivate Resolved Problems: Pay attention to diagnoses with closely related ICD codes. Review the chart to determine the diagnosis and edit as appropriate.. Remove Allergies: Click the button, select Other and enter Entered in Adverse Reactions as the reason for deletion. Enter in the Adverse Reaction component.

5 Un-coded Diagnoses: Assign an ICD 9 code for each diagnosis. Determine if diagnosis is an ongoing problem. Inactivate resolved problem if indicated. Click the button and change status to Inactive.. Redundant Entries*: Click the button and select Duplicate Entry as the reason for deletion. Delete the most recent entry if notes or date of dx are not entered. Add the procedures to Historical Services.. Consideration: Address diagnoses related to a personal history. Click the button and change status to Personal History. This will change the status to Inactive and will display Personal History in the Class column. Add Nephrectomy to Historical Services. 4. Remove Inappropriate Entries*: Click the button, select Other and enter Inappropriate Entry entered in Family History as the reason for deletion. Enter in Family History component. 5. Considerations: Some diagnoses require clinical judgment to determine if the diagnosis should remain on the Problem List. This will need to be determined at the local site as to which diagnoses should be retained. Some examples are: ASA Prophylaxis, Tobacco Use Disorder, Alcohol Abuse, etc. 6. Remove Inappropriate Entries: Click the button and select Entered in Error as the reason for deletion. Look in Historical Diagnosis to determine if a diagnosis for Obesity was entered by a provider. Obesity can be then be added to the Problem List. This can be done by clinical staff members that cannot make a diagnosis. *NOTE: This example includes inactive problems. It is recommended that the focus be cleaning up active problems. Although, this demonstrates the need to inactivate historical diagnoses and add (or make sure) family history is entered in the Family History component.

6 Remove Inappropriate Entries: Click the button and select Entered in Error as the reason for deletion.. Remove Inappropriate Entries: Click the button and select Other and enter Entered in Historical Services in the free text field as the reason for deletion. Enter procedures in the Historical Services component.. Un-coded Diagnoses: Assign an ICD 9 code for each diagnosis. 4. Remove Allergies: Click the button, select Other and enter Entered in Adverse Reactions in the free text field as the reason for deletion. Enter in the Adverse Reaction component. 5. Inactivate Resolved Problems: Click the button and change status to Inactive. Add Nephrectomy to Historical Services. 6. Redundant Entries: Click the button and select Duplicate Entry as the reason for deletion. Delete the most recent entry if notes or date of dx are not entered. 7. Considerations: Pay attention to diagnoses with closely related ICD codes. Review chart to update as appropriate. 8. Remove Inappropriate Entries: Click the button and select Entered in Error as the reason for deletion. 9. Redundant Entries: Click the button and select Duplicate Entry as the reason for deletion. Delete the most recent entry if notes or date of dx are not entered.

7 Problem List Clean Up Tips Select Active Only to display problems with an Active Status. Use the sort feature on the ICD column to sort problems by the ICD code. Double click on the ICD header to sort. Problems with duplicate or similar ICD 9 codes will be displayed together. Pay attention to diagnoses with closely related ICD codes. Working with coding staff to assist with this. Some diagnoses require clinical judgment to determine if the diagnosis should remain on the Problem List. This will need to be determined at the local site as to which diagnoses should be retained. Some examples are: ASA Prophylaxis, Tobacco Use Disorder, Alcohol Abuse, etc. Address diagnoses related to a personal history. Click the button and change status to Personal History. This will change the status to Inactive and will display Personal History in the Class column. Add Nephrectomy to Historical Services. Review the diagnoses listed in the Historical Diagnosis panel to determine ongoing problems. Identify ongoing problems that have not been added to Problem List. Avoid spending a significant amount of time reviewing charts. Collaborate with clinic staff to determine local policies for decision making with diagnoses displayed on the Problem List that may be considered episodic or acute in nature (i.e. headaches/cephalgia, allergic rhinitis, etc.)