Given the ease with which tools like Dragon Medical One can be used to dictate documentation, clinicians may be tempted to record a patient's problems as narrative, instead of updating the patient's problem list and pulling it into a note.
Does this matter? Yes, in many ways.
A patient’s health problems determine which ordering tools (e.g., Order Sets), documentation aids (e.g., Forms), navigators (e.g., Express Lanes), patient resources (e.g., questionnaires) and billing shortcuts are offered to speed-up workflows.
Good problem lists provide the scaffolding for a clear, concise and safe health record. They connect workers and workflows both within and without Connect Care. Problem lists are part of standardized patient summaries exchanged between information systems, including community Electronic Medical Records (EMR) and patient and provider portals.
Accordingly, safe Problem List management is among the "Minimum Use Norms" expected of all prescribers. Problem List reconciliation is also among the performance metrics tracked for continuing improvement. "Problem List Norms" have been developed to clarify essential practices for all who participate in patient care.
This is the first in a series of tips about how to make Problem List management fast, easy and meaningful. All tips are gathered in a "Problem List" tip theme.