problem list

In health IT, a problem list is a designated section of a patient's medical chart that details the most important medical information.

In health IT, a problem list is a designated section of a patient's medical chart that details the most important medical information. The information, which is meant to be a succinct overview that can be absorbed at a glance, includes diagnoses such as asthma and hypertension, family history and past tests and procedures.

According to the American Health Information Management Association (AHIMA), the problem list offers four potential benefits:

  • It enables more customized care through the identification of the patient’s most important health information.
  • It can help identify "disease specific populations" through data analysis.
  • It can help evaluate standard measures for specific practitioners and health care organizations.
  • It can identify patients for relevant research studies

In the traditional sense, the structure of the problem list varies widely from physician to physician, but a common placement is on the top page of the patient's chart, on the left-hand side, above the medication list.

As the health care industry transitions to electronic health records (EHRs), the problem list is recognized as one of the core meaningful use criteria, leading to the need for standardization in content and structure in order to be compatible for health information exchange (HIE). To standardize the lexicon, items on the problem list can be inputted using one of two sets of medical coding -- ICD-9-CM or SNOWMED CT. (As of Oct. 1, 2013, health care providers in the U.S. will have to use ICD-10-CM, as use of ICD-9 will be phased out.)

See also: health informatics, Automatic Identification and Data Capture (AIDC), document capture, clinical decision support system (CDSS), legal health record

This was first published in November 2011

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