Easily keep a list of a patient's medical problems in the chart.

In the Chart Module, double-click the Medical area. Click the Problems tab.

Add Problem: Add a problem from the Problem List. See Add a Problem below.

Show Inactive Problems: Check to 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 EHR InfoButton may show if EHR is turned on.

Active problems also show in the Chart Module medical area in bold red. Every time a user adds, edits, or removes a patient problem, an entry is made in the Audit Trail.

Add a Problem

1. Click Add Problem to open the Problem List. The patient's current active problems highlight.
2. Double-click on the problem to add it to the patient's list of problems.

Edit a Problem

Users can change a problem's status or enter start/stop dates or notes. To change SNOMED CT Codes or ICD Codes, see Problem List instead.

Double-click the problem to edit.

Status: There are three options: Active, Resolved, Inactive. Resolved usually 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.

Note: Enter any patient-specific notes.

Problem Type: Must be set to Problem for this condition to show on a Summary of Care.

Functional Status: If Problem, this shows under Problems. If CognitiveResult, CognitiveProblem, FunctionalResult, or FunctionalProblem, this shows under Functional Status on a Summary of Care.

Convert: Only visible when a problem marked as Other is imported from an eForm. Enter the type of problem in the Note box, then click to convert Other to the specified problem. Once converted, the Convert button is removed. If the problem already exists in the Problem list, the existing problem is used. If a new problem is entered, the new problem is added to the Problem list.