Maintain an up-to-date problem list of current and active diagnoses.
Measure:
More than 80 percent of all unique patients seen by the eligible professional have at least one entry or an indication that no problems are known for the patient recorded as structured data.
Clinical Importance
Accurate active problem lists have been a mainstay of efficient and effective primary care for years, providing a fast overview of a patient’s history. Now with EHRs, not only is problem list maintenance easier, but an EHR provides this information to all of your clinical staff, making their time with the patient much more efficient. Finally, having quick and easy access to a current problem list improves the efficiency and effectiveness of your practice’s on-call team during evening coverage.
Lessons from the Field
A patient problem list is subject to change during each appointment, whether it is by adding new information or removing outdated information. Providers utilize their nursing staff by having them review the problem lists when prepping the patient’s chart. Any notes regarding rehabilitation or specialty care trigger an in-depth review to ensure the patient problem list is all-inclusive. Providers also utilize clinical summaries as a mechanism for review and correction of problem lists, encouraging their patients to be active in their care and identify when there might be outdated information such as obesity or smoking status.
Prior to using EHRs, providers depended on paper charts and faxes to make sure their patients had accurate problem lists. Now, with EHRs, problem list maintenance is easier and provides a much needed view of a patient’s history. Provider acceptance in using shared electronic chronic problem lists can be difficult, but it can be helpful to demonstrate how the functionality can improve care, reduce redundancies for patients, and decrease office staff time.
Prior to using EHRs, providers depended on paper charts and faxes to make sure their patients had accurate problem lists. Now, with EHRs, problem list maintenance is easier and provides a much needed view of a patient’s history. Provider acceptance in using shared electronic chronic problem lists can be difficult, but it can be helpful to demonstrate how the functionality can improve care, reduce redundancies for patients, and decrease office staff time.