Best Practices for Problem Lists in an Electronic Health Record

CHICAGO, January 14, 2008 — An effective problem list provides a clear, descriptive summary of a patient’s health history. This list requires detailed terminology usage that allows the transfer of information across healthcare systems and within the various areas of the electronic health record (EHR), according to an article in the January issue of the Journal of AHIMA.

The article examines the use and maintenance of problem lists in health records. It also highlights how electronic environments support additional functionality to share information and assist with the continuation of care.

Problem lists require standard approaches to manage data quality. The best practice is to avoid entering bad data, audit and then carefully remove irrelevant data or resolved problems.

 A multitude of challenges exist when implementing and maintaining problem lists in the EHR, but resources are available to provide solutions for success. The Journal article outlines some of the issues and barriers associated with the effective use of problem lists within EHR systems.

Additionally, four appendixes also appear in the online version of this article: definitions of problem lists from authoritative sources; candidate terminologies for encoding problem lists; resource list for additional research and guidance; and best practice considerations for problem lists.

Read the complete article in the January issue of the Journal of AHIMA or online at www.ahima.org.

About AHIMA

AHIMA is the leading professional Association representing more than 51,000 specially educated and certified health information management professionals working throughout the healthcare industry.  HIM professionals serve healthcare and the public by managing, analyzing, and utilizing data vital for health system management.