As clinical practice adopts electronic patient records as a means for automating documentation and reporting requirements, often it becomes convenient to recreate paper forms in electronic format. Evidence of this practice continues as clinicians request a copy of someone’s “form” because they are in the process of building their hospital’s electronic clinical record. This short cut will be greatly appreciated.
The latest request for a copy of your hospital’s patient problem list did not sit easy and prompted an email to the requester in an attempt to better understand what exactly was required. The response from the clinician given the task of improving the “problem list” in the new electronic medical record was having trouble finding rehabilitation specific problem list formats and wondered if others could help with what they were using.
The problem list serves a variety of uses for clinicians and non-clinicians in diverse healthcare settings. It can provide a succinct view of a patient’s health status and therefore must be used and maintained to meet different needs. A primary care physician is concerned with chronic and acute conditions. A specialty provider may focus only on a subset of problems relevant to that area of medicine. A rehabilitation provider may address the functional problems required for discharge. Other clinicians may use the problem list for tracking conditions for specific care delivery goals.
Although problem lists are used as a source of information for clinical care, in an electronic environment they are considered a source for secondary data use, including quality measurement initiatives and research. Disparate needs present challenges when creating and maintaining the problem list. By including psychosocial, cultural and other key information about the patient, it may lengthen the problem list and compromise its utility as a quick reference about the patient’s overall health condition. The record must be created and used for patient care rather than reporting for incentives or for payment. The problem list serves the dual purpose of providing a brief, formal summary of the patient’s illnesses and of acting as a tool for organizing the routine documentation of the care team’s decision-making process and the plan for and results of care.
A lack of standards for problem lists (and indeed the definition of a “problem” to be included) is contributing to poor service for both caregivers and patients. Problem lists can be a healthcare organization’s best friend or worst nightmare. Electronic record systems can extend the benefits or compound the issues. The same forces that make problem lists valuable for patient care and secondary data uses can also create barriers to clinical efficiency. Relying upon other’s example of how they do it may not translate to success in your hospital.
Accountability and Meaningful Use will demand broader attention to insure the patient problem list identify and coordinate all areas of care centric to the patient. Patient problems are not just the hospital’s barriers to discharge.
