View, enter, or edit a patient's problems on the Medical window, Problems tab. To open the window:
- In the Chart module, double click the pink medical area.
- Click the Problems tab.
Add Problem: Add a problem from the Problem Master List.
Show Inactive Problems: List problems with an 'inactive' status.
Problems: A list of entered problems. Double click a problem to change start/stop dates, status, or notes. The InfoButton may show if EHR is turned on.
Active problems also show in the Chart module medical area in bold red. Every time you add, edit, or remove a patient problem, an entry is made in the Audit Trail.
Add a Problem
- Click Add Problem to open the Problem Master List. The patient's current active problems will highlight.
- Double click on the problem to add it to the patient's list of problems.
Edit a Problem
You can change a problem's status or enter start/stop dates or notes. To change SNOMED CT codes or ICD codes, see Problem Master List.
- Double click the problem.
- Enter the problem details:
Status: There are three options: Active, Resolved, Inactive. Resolved usualy means an acute problem that will never return (e.g fractured hip or an infection). Inactive usually means a problem that may return (e.g. diabetes or angina).
Start/Stop Date: Enter the dates, or click Today to insert the current date. (optional)
Note: Enter any patient-specific notes. (optional)
EHR only: The settings below determines if this problem shows on a Summary of Care.
Problem Type: Must be set to Problem for this condition to show.
Functional Status: If Problem, this will show under Problems.
If CognitiveResult, CognitiveProblem, FunctionalResult, or FunctionalProblem, this will show under Functional Status.
- Click OK to save.