Problem Database Template by mme89049


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									                                                                                             Clinical Information Systems

Problem List                                                                                 Phone: 653-1005 (North)
                                                                                                     629-1180 (South)
Quick Reference Card                                                                         Visit CIS on the D-H Intranet

Using the Problem List
The Problem List allows the user to generate and update a list of patient specific problems. Prob-
lems added to the list are field defined, based on ICD-9 code. They will be selected from a dic-
tionary of SNOMED medical nomenclature. The SNOMED dictionary provides a common lan-
guage which enables a way of capturing, sharing and aggregating health data across specialties
and sites of care. The Problem List is the foundation for future Outpatient Charge Capture devel-
                                                                                                   There are 4 sections to the prob-
                                                                                                   lem list:
                                                                                                   • Active Problems
                                                                                                   • Inactive Problems
                                                                                                   • Resolved Problems
                                                                                                   • Problems Entered in Error

                                                                                                   You can expand the list one at a
                                                                                                   time by clicking on the + in front
                                                                                                   of the listed problem, or use the
                                                                                                   Expand All. This will show the
                                                                                                   detail on this window without
                                                                                                   having to open the problem de-
                                                                                                   tails window.

                                                                                                   If you’d like to see the active
                                                                                                   problem list in a different order,
                                                                                                   place numbers in the field pre-
                                                                                                   ceding the problem name and
                                                                                                   click on the Re-Sequence but-

                                                                    Insert into Note Templates or use a Quick Insert

For a limited time after the 2006.4 release (December 2006),
when creating a new problem, you will be prompted with an
option to Create New, Import Free-Text Problem, or Import
Billing Hx Problem. When you choose to import a problem,
you will be prompted with a window that displays the previous
versions of the:

Free-Text Problem List
                                                                     You can use the Insert menu from the note template manager to
Billing Hx List (Encounter Summary)
                                                                     store on existing templates, or you can insert the problem list on
                                                                     the fly with the Quick Insert menu available from the right click
If the patient is being seen for a recurring or existing problem,
                                                                     menu within the note. The template/quick insert will allow you to
you may be able to shorten the data entry time required to im-
                                                                     automatically populate your note with as much or as little detail
plement this new problem list by choosing to import the prob-        about the problem as you choose.
lem using the Import Billing Hx Problem.
                                                                                                                        December 2006
                                                                                     Clinical Information Systems

Problem List                                                                         Phone: 653-1005 (North)
                                                                                             629-1180 (South)
Quick Reference Card                                                                 Visit CIS on the D-H Intranet

Entering a Problem

                                                                                           You may search for a problem
                                                                                           several ways:
                                                                                           •    By selecting 'Name Search'
                                                                                               and entering a string of text
                                                                                               describing the problem.
                                                                                           • By selecting 'ICD-9 Search'
                                                                                               and entering an ICD-9 code.
                                                                                           • Select 'Health Maintenance'
                                                                                               which will allow you to
                                                                                               manually enter a list of Pre-
                                                                                               ventive Care or Develop-
                                                                                               mental Landmarks.

                                                                                           Note that MI was entered as the
                                                                                           problem. When a search was
                                                                                           completed, Myocardial Infarc-
                                                                                           tion was selected in the middle
                                                                                           section of this window. By sin-
                                                                                           gle clicking on Myocardial In-
                                                                                           farction, the database searched
                                                                                           again and was able to give 3
                                                                                           More General descriptions
                                                                                           (upper section of window) and
                                                                                           19 More Specific descriptions
                                                                                           (lower section of window). As
                                                                                           the provider, the decision of
                                                                                           level of specificity is up to you.

 Each time you single click on a problem description, the database will search for more general and more specific prob-
 lems. To Select the problem, highlight the description and click on the Select button. If the desired problem description
 is in the middle section of the window, you may also double click on the problem to select it. Note: Double Clicking on
 a description in the lower or upper sections of the window will place the item in the middle section of the window.

Changing a Problem…
                                                                 •   You may ‘Rename’ the problem. Click the ‘Rename’
                                                                     button and the problem search dictionary will appear.
                                                                 •   You may change the date using the calendar (click on
                                                                     the upside down triangle button), or by typing in a
                                                                     date using one of the following formats: MM/DD/
                                                                     YYYY, MM/YYYY, YYYY. If you leave the date
                                                                     field blank, “unknown’ will display in the Date of
                                                                     Onset column on the list.
                                                                 •   The status may be changed to either Active, Inactive,
                                                                     Resolved or Entered in Error.
                                                                 •   To annotate, begin typing in the Details space. Click
                                                                     ‘Enter’ to update the list. A history of edits can be
                                                                     viewed by clicking on the ‘Previous Versions’ tab.

                                                                                                               December 2006

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