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Patient Summary: Problems

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[Navigation] Medical > Patient Summary: Problems

[Accordion] Overview

The Patient Summary: Problems feature allows you to maintain a comprehensive list of a patient’s current and past health problems. This helps ensure accurate tracking of diagnoses and medication prescribing. 

Using the Patient Summary: Problems feature, you can also monitor a problem’s current status, track important dates like onset or resolution, and assign responsibility by linking each problem to the appropriate provider. 

[Permissions] The staff member must have Full permissions to the Patient Summary module [Staff > Staff Info > System Permissions > Patient Summary]

[Accordion] Getting Started

Use the Patient Summary: Problems feature to document and manage a patient’s active and historical health issues, ensuring accurate diagnosis tracking and informed clinical decision-making.

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  • [[img:add >> lbl:New]] Add a new problem for the selected patient
  • [[img:person_search >> lbl:Patient Lookup]] Brings up the Patient Lookup screen, where you can select a patient. Once selected, the patient’s problems will automatically load
  • [[img:prescriptions >> lbl:eRx Portal]] Opens the ePrescribing Portal
  • [[img:sync >> lbl:Sync Data]] Automatically sync data between the Patient Summary module and the eRx Portal, ensuring that updates made in one are reflected in the other. This ensures that the latest/updated problems, allergies, medications, and prescriptions are accurately reflected in the Patient Summary and eRx Portal for consistent record management. This is a two-way sync, so any Diagnoses/Problems you add in the eRx Portal will also sync back to Patient Summary: Problems 
  • [[lbl:Patient Summary: Modules]] Access the other Patient Summary features (Allergies, Medications, Prescriptions) directly through this button
  • [[img:help_outline >> lbl:Help]] Click/Tap to view the help article for guidance on this form

Adding a new Problem:

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  1. Problem Input:

    • Select from Code Set: Allows you to select from a library of medication data. Choose the code classification to use: ICD-9, ICD-10, or SNOMED-CT. The formats available are based on what is enabled in the Options form at Formats > Patient Summary Problem Formats 
    • Code Set: Auto-populated based on your selection (ICD-9/ICD-10/SNOMED-CT)
    • Code (required): Auto-populates the code based on your selection (ICD-9/ICD-10/SNOMED-CT) or from the ePrescribing module
    • Description (required): Auto-populates the description based on your selection (ICD-9/ICD-10/SNOMED-CT) or from the ePrescribing Portal
    • Remarks: Additional comments or clarifications about the problem or diagnosis

  2. Problem Details:

    • Status (required): Indicates the current state of the problem: Active, Resolved, Inactive, or Erroneously Charted.
      • Active: Indicates that the problem is currently affecting the patient and requires ongoing monitoring, treatment or follow-up
      • Resolved: Marks a problem that has been successfully treated or no longer affects the patient 
      • Inactive: Used for problems that are not currently impacting the patient’s care but are not fully resolved. If the problem does not need to be looked into, it can be marked as Inactive
      • Erroneously Charted: Applied when an entry was made in error. Since problems cannot be deleted from the record, they can be marked as Erroneously Charted (along with the Erroneous Date) to ensure that the entry should not be considered clinically relevant
    • Onset Date: The date when the problem began or when it was recorded
    • Resolved Date: The date when the problem was marked as Resolved
    • Inactive Date: The date the problem was marked as Inactive
    • Erroneous Date: Used when an entry is determined to be an error (records cannot be deleted)
    • Assigning Provider (required): The staff member assigned to record the problem
    • Chronicity (required): Indicates whether the problem is Acute/Self-Limiting or Chronic/Long-Term
      • Acute/Self-Limiting: Refers to conditions that develop suddenly and usually resolve within a short period, either on their own or with minimal medical intervention
      • Chronic/Long-Term: Refers to conditions that persist over an extended period, often lasting for months or years, and may require ongoing management or treatment
    • Comments: Additional notes relevant to the problem entry

[Accordion] FAQs

[Q] Can I delete a problem entry from the Patient Summary: Problems?

[A] No. Problem entries cannot be deleted. If an entry is made in error, mark it as Erroneously Charted and provide the Erroneous Date. 

[Q] Can I add both active and historical problems?

[A] Yes. You can document new active problems and also record historical or resolved issues.

[Q] How do I mark a problem as resolved or inactive?

[A] Select the problem and update its status to “Resolved,” “Inactive,” or the equivalent status provided in the form.

[Q] Are the problems linked to diagnosis codes?

[A] Yes, each Problem can be associated with a diagnosis code, ensuring accuracy in clinical and billing documentation.

[Q] Can I attach notes or comments to a problem?

[A] Yes. You can add notes or clinical details to each Problem to provide more context.

[Q] Does the Patient Summary: Problems form support ICD?

[A] Yes. Problems can often be linked to ICD-10 or other standardized codes for consistency in clinical documentation.

[Accordion] Related Articles

Patient Summary: Allergies

Patient Summary: Medications

Patient Summary: Prescriptions

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