Problems
Documenting the patient’s medical conditions in the problems list in an efficient way to quickly inform practitioners in the clinic of the conditions they should be aware of when treating the patient.
Using problems will:
- Increases continuity of care when multiple
clinicians are involved in patient care.
- Updates the problems into the reference panel to
view while in a chart note.
- Will export to the CED as part of Community
Information Integration (CII) and improve continuity when the patient is
receiving care outside of the patient medical home.
They are found at the top of the overview page on a patient chart as well as the problems tab. Problems can also be found in the reference panel.
How to add a problem:
- Click the problem tab and click new or click the
plus sign in the problem history on the reference panel.
- Search the problem lookup window.
- Select applicable problem entry with a double
click.
If you would like to create multiple problems at once, click the 'save + add' button to add additional problem list items.
*Note best practice is to use the diagnosis codes entries, this will keep problem labelling consistent within a clinic.
- Complete the problem with additional information
as required.
- Severity, status, and doctor.
- Start date – defaults to today’s date.
- End date – use if the problem is not a constant
problem.
- Important check box – this will bold the problem
entry and place it at the top on the overview page as well as the problem list
on the left in the problem tab.
- Confidential check box – this will replace the
title of the problem with ‘confidential’ and will hide the details of it unless
you click on it and override the confidentiality flag. (*Note this will be
documented on the security disclosure logs).
- Next tests due – place a future date in here,
there is a report to pull all patients with an overdue ‘next tests due’ field.
- Notes – additional notes such as diagnosis date,
specialty practitioners, family history notes etc.
- Click save.
How to delete a problem:
Right click on the problem entry on the patient overview or the reference panel, or click the problem tab, select the problem entry.
Click delete.
A warning message will pop up, select applicable response.
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