Unity Point Health PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD

Transcription

1 Unity Point Health PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD

2 Introduction The problem list is a critical part of electronic documentation and serves as a communication tool between all care providers.

3 Introduction Historically, the problem list has been used inconsistently and did not accurately portray the patient s current and historical issues.

4 Introduction

5 Introduction With the implementation of a new/standardized Electronic Health Record (EHR), we move toward an integrated medical record and single common problem list between the ambulatory and inpatient settings. All providers and clinicians involved in the care of a patient must be committed to creating and maintaining accurate and up to date problem lists that are not specific to a given provider, specialty or setting, but are instead dynamic and patient centric.

6 Introduction In this module, we will review the Rules of Engagement and Best Practice Guidelines for the use and maintenance of a shared problem list. This module is intended for all physicians, advanced practitioners and clinical staff that contribute to or maintain the patient s problem list. Both inpatient and ambulatory guidelines will be covered.

7 Definitions Problem list The problem list is defined as a patient focused, comprehensive, dynamic listing of significant or ongoing medical, social, surgical, or family history issues affecting the patient s overall health and plan of care. Active Problem A current medical issue that is being actively managed.

8 Medical History History Definitions A significant past medical issue that is no longer being actively managed.

9 Surgical History Surgical History A historical surgery or procedure, including interventional or invasive procedures.

10 Family History Family History A significant medical issue/diagnosis affecting the patient s family member(s)

11 Social history Social History A significant social/lifestyle/demographic related finding

12 Definitions Principal Problem The primary medical issue identified and associated with an Inpatient encounter. Visit Diagnosis A current medical issue/diagnosis that is associated to a specific visit or encounter and may or may not be reflected in the active problem list. Chronic Problem A current, active medical issue that is being managed on a long term basis.

13 Problem List The Basics In both settings of care, the provider is responsible for the timely creation of the problem list. In the inpatient setting, the list must be reviewed and reconciled within 24 hours of admission, at discharge, and as needed through out the stay.

14 Problem List The Basics In the ambulatory setting, pertinent problems and history should be documented at the first visit. Additional history should be added at each subsequent visit. The full history should be documented at the time of the annual exam and annually thereafter.

15 Problem List The Basics The provider managing a given problem is responsible for adding/maintaining the problem on the appropriate list. Others involved in the care of the patient should contribute to the list as needed. Clinical staff may edit or add to a problem list under the direction of the provider. Problems should be resolved as appropriate to avoid clutter and confusion in the problem list.

16 Problem List The Basics During each encounter, the provider is responsible for adding and updating to the highest appropriate level of specificity for the encounter or visit diagnosis used for billing. The problem list should contain the more general problem.

17 Problem List The Basics The mark as reviewed button should be used upon admission, discharge, as needed throughout the ambulatory stay, and at every ambulatory visit. This should be used for all of the types of problem lists, and each time a list is edited or reviewed.

18 Problem List Reconciling at Discharge The provider must reconcile the problem list upon discharge from the hospital setting. Problems should be marked as resolved if appropriate.

19 Problem List Reconciling at Discharge Because resolved problems do not automatically file to the PMH, the file to history button should be used from the details link..

20 Problem List Reconciling at Discharge Problems should not be deleted or removed, except in the case of an error or duplicate entry. Problems that were inadvertently omitted during the stay but are critical to the patient s on going management should be added. Symptoms or other non specific problems should be updated to the more specific problem by using the Change Dx functionality

21 Review Question In both the inpatient and ambulatory setting, the nurse or clinical staff are responsible for maintaining the problem list. True or False?

22 Review Question False The physician or advanced practitioner is responsible for the maintenance of the problem list.

23 Active Problem List The Active Problem List should contain problems for which the patient is actively being treated for more than short term management, or require continuous management. In the inpatient setting, problems that are usually short term (ex. Hypokalemia) may be on the problem list while they are being actively managed, and then resolved, if appropriate, prior to discharge. Problems can be prioritized, have comments added, include onset dates, etc. All pertinent details should be added at the time the problem is identified and documented.

24 Active Problem List The active problem list should not include: diagnoses with two concepts. i.e. Diabetes w/neuropathy. Instead use Diabetes and Neuropathy. acute problems or visit diagnoses (unless persistent and requiring on going management) instances of r/o diagnoses health maintenance items and routine screenings

25 Active Problem List All Problems should be designated for sharing with the patient. Shared problems will be available to the patient via the patient portal. The principal dx and the hospital problems should be marked accordingly during the inpatient workflow. Follow the Reconciliation of Problems at Discharge for maintenance and clean up of problem list at time of discharge.

26 Review Question The problem list should not contain health maintenance items or screening diagnoses. True or False?

27 Review Question True Health maintenance items and screening diagnoses should not be documented as active problems.

28 Past Medical History The Past Medical History (PMH) should contain problems significant to the patient s history, but are no longer being treated or do not require on going management. Example: Cholecystitis, acute with cholelithiasis MM/DD/YYYY

29 Past Medical History Active problems listed on the Problem List should NOT be duplicated in the PMH. In Epic, functionality exists to easily move problems between the two lists. PMH should NOT contain multiple instances of the same problem.

30 Past Surgical History Past Surgical History should include all procedures related to surgeries including invasive or diagnostic procedures and endoscopies with the date if known. Procedures or surgeries should be added to the past surgical history at the time of the event or as soon as possible following the event. Example: Cholecystectomy MM/DD/YYYY

31 Family History The family history should contain all history problems pertinent to the patient If multiple family members have the same condition, each instance should be listed. If specific information is not available, general problems can be added with a comment indicating other impacted family members.

32 The family status worksheet should include all 1 st degree relatives Living status and age of death are available by right clicking in the status column Age of onset is available by right clicking on check box specific to the diagnosis If a problem is not available on the worksheet, it can be searched and added. Family History

33 Social History The social history list should contain all social history problems pertinent to the patient. Examples would include smoking status and use of nicotine products.

34 Wrap Up Thank you for reviewing this module. Please click the Take Test button to complete the assessment. For additional information, please refer to the Rules of Engagement and Best Practices Guidelines document previously distributed. For questions, please contact your regional informaticist or EHR support team member.