By Rose T. Dunn, MBA, RHIA, CPA, FACHE
Are your problem lists a problem? Providers have enough documentation burdens already. For providers, maintaining problem lists takes a backseat to patient care…as it should. However, an accurate and complete problem list can facilitate patient safety and care. Coders and documentation specialists have a critical role to play in support of this powerful tool used to tell a patient’s medical story.
You can think of the problem list as a Table of Contents highlighting the major chapters in a patient’s medical history:
- A compilation of their problems and conditions
- Active current conditions
- Chronic conditions
- Past or “personal history of” conditions that bear on current treatment
- Significant past or resolved conditions that are no longer actively being treated
- A resource for clinical decision support tools to prevent medical error and improve patient care
Let me emphasize “significant” when deciding whether past or resolved conditions should be included on the problem lists. The criteria would be to include past or resolved conditions that may help a provider to understand and treat the patient in the present. There is a difference between a long-ago cut on your finger requiring two stitches and a history of cancer.
Problem lists offer benefits beyond the immediate patient-provider relationship. If kept current, problem lists can serve as a source of comparative data for research, drivers for quality measures, and support for secondary data reporting, such as registries.
While we may all agree on the concept of problem lists as beneficial, in practice, problem lists are beset by inconsistency and a lack of standards. The most important risk is that posed to patient care. Maintaining a problem list for a patient that is both accurate and succinct will help practitioners know what is important about the patient at the time the patient is being treated.
Appreciating the value of the problem list to ensure quality patient care and addressing the inconsistency and lack of standards affecting the usefulness of problem lists is both a challenge and an opportunity for HIM professionals.
HCC Problem Lists: Challenges and Opportunities
Are your problem lists a problem? An up-to-date and accurate problem list can facilitate patient safety and care as well as being a key aspect of some risk adjustment contracts. HIM and CDI specialists have a role to play. Learn more here.