Problem lists facilitate continuity of patient care by providing a comprehensive and accessible list of patient problems in one place. Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution.1 They are an important communication vehicle used throughout the entire healthcare continuum.
Today the healthcare industry is transitioning from free-text expression of problems to encoded problem lists to facilitate information retrieval and meet requirements of the federal meaningful use program, which pays incentives for the implementation of electronic health records (EHRs).
Capture and storage of information in standard encoding systems support data sharing, provide a more practical and accurate way to conduct data analysis, and support the ability to retrieve information about both common and unique problems. Well-designed problem lists provide a clear picture of patient issues requiring consideration or intervention and frequently serve as a table of contents for more comprehensive health record details. In addition, problem lists offer a data source for research studies, quality measures, and other secondary data-reporting requirements.
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Acker, Beth; Bronnert, June; Brown, Teresa; Clark, Jill S.; Dunagan, Betty; Elmer, Tracy; Goodell, Suzanne; Green, Kate; Heller, Pamela; Holmes, Casey; Imel, Margo; Johnson, Kathy; Kallem, Crystal; Loucks, Melanie; Patel, Sheetal; Reed, Debbie A.; Scichilone, Rita; Tegen, Anne L., Journal of AHIMA, 82(9), 52-58
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