Problem List Definitions Conventions Major Functions Table of

Problem List Definitions & Conventions

Major Functions § Table of Contents for the Health Record § Information Bulletin Board for Communication Among Providers § Synopsis of Medically Significant Events

Active Problems § Include important medical, social, and psychiatric problems § Have clinical significance and currently affect the patient (Diabetes) § May be presently quiescent but are still at high risk to recur (CHF) § May be temporarily active (Pregnancy, Burns)

Inactive Problems § Have a tendency to recur § Place the patient at risk § Include resolved conditions § Include positive skin test, OB, or birth information

Surgery § Although surgical conditions that place a patient at risk are usually included in a problem list, they should not be added to the Problem List because they are displayed on the health summary in the History of Surgery section. Use mnemonic SHX to enter a surgery

Problems That Are Always Considered Active § § § § Abuse Alcohol Related Injuries Allergies Amputations Blindness Deafness Diabetes Epilepsy Hypertension Paralysis Recurrent Otitis Media Rheumatoid Arthritis Suicide Attempts Violence Related Injuries Recurrent Urinary Tract Infection

Where to Look for Active Problems § Last five encounters or past six months § Inactive Problem List § Hospital discharge reports § Consultants’ reports