Using the Problem List

to Improve

DocumentationDave Mooradian, M.D.CMIO

Using the Problem List - Admission• When entering a new hospital problem,

the problem list calculator will assist in meeting documentation specificity requirements for ICD-10 and Present on Admission.

• Use the “Overview Note” section in order to include problem specific plans within the Admission H&P template when entering a new hospital problem or addressing an existing hospital problem.

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Using the Problem List - Admission

• Select appropriate modifiers to make diagnoses more specific for ICD-10

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Using the Problem List - Admission

• Document Present on Admission status and Overview note to summarize plan

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Using the Problem List - Admission

• Click Create/Edit Overview to enter Overview note on an existing problem

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Using the Problem List - Admission

• Click H&P Notes from within the Admission Navigator

• The problem list with overview notes are automatically included

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Using the Problem List - Admission

• If Present on Admission is not addressed on the Problem List (PL), a Best Practice Advisory (BPA) will display that will redirect you to the PL for completion

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Using the Problem List – Problem Oriented Charting

• Used to document daily Progress Note

• Accessed via the Problem Oriented Charting Navigator

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Using the Problem List – Problem Oriented Charting

• First section – Select Hospital Service will default for those with only one specialty defined.

• MUST be completed in order to use Problem Oriented Charting

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Using the Problem List – Problem Oriented Charting

• Subjective/Objective section• Upon opening smarttext appears• Complete required ***• Each specialty’s note will be independent

of each other

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Using the Problem List – Problem Oriented Charting

• Problem List section• Allows problem specific assessment

and plan notes• Click Create Assessment & Plan Note

and document for each problem you are addressing

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Using the Problem List – Problem Oriented Charting

• Enter text• Click Next (or use Voice Command

for Next) to move to the next Problem’s Create Assessment & Plan Note

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Using the Problem List – Problem Oriented Charting

• When all desired assessment and plan notes are complete, click Generate Note

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Using the Problem List – Problem Oriented Charting

• Note is generated in APSO format

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Using the Problem List – Problem Oriented Charting

• There are 2 options for completing the Physical Exam, using a “dot phrase” or using Notewriter.

• To complete via “dot phrase”, within the note under Physical Exam type “.pexmale” or “.pexfemale” or a physical exam of your choice.

• Complete smartlists and remainder of progress note and Sign.

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Using the Problem List – Problem Oriented Charting

• To complete Exam in Notewriter, Click Pend.

• Click “Edit in Notewriter” in Progress Notes section of navigator

• Notewriter opens with Physical Exam Smartform.

• Complete the physical exam, remainder of progress note and Sign.

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Using the Problem List – Problem Oriented Charting

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Using the Problem List – Problem Oriented Charting

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Using the Problem List - Discharge

• Via the Discharge Navigator, indicate problems that are resolved

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Using the Problem List - Discharge

• Click Discharge Summary on the Discharge Navigator

• A list of all hospital problems during the encounter, both active and resolved are listed with the present on admission status

• Complete remaining elements of template using Voice to Text.

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