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EHR:  Maintain Problem List

This information is old and has been replaced by the Modified Stage 2 requirements per the Final Rule, 10/7/2015.

EHR Stage 1: Core Measure 3

Overview

A patient's Problem List should contain an up-to-date list of current and active problems or an indication that no problems are known.

Exclusions Available? No

Resources:

Calculations

In the Stage 1 Measures Report, the provider percentage for ProblemList is calculated using the following information:

  • Denominator: All unique patients with at least one completed procedure by the provider during the reporting period.
  • Numerator: Patients in the denominator who have at least one problem in their Problem List, or an entry with an indicator of 'no problems known'.

Setup

EHR General Setup

There are three setup steps:

  • Associate all problems in the Problem Master List with a code: 
    - Problems must have a SNOMED CT or ICD-9 code to affect the numerator.
    - Problems must have a SNOMED CT code to show on Summaries of Care and Clinical Summaries.
  • In the master problem list, create a problem that indicates 'no problems known'.  It can be named anything.  You may want to use SNOMED CT code 160245001 which has a description of 'No current problems or disability (situation)'. 
  • In Chart Module Preferences, select the 'no problems known' problem as the 'Indicator that patient has no problem'. 

Instructions

Patient Problem List
Webinar: Documenting Current Problems, Medications, and Allergies (GoToMeeting)

 

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