Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Creating a Problem List Weight gain + edema Exertional dyspnea but clear lungs Pallor High blood pressure + history of hypertension Tachycardia S4 gallop Risk factors for coronary artery disease Ex-smoker To-Do list for patient care Grouping Group related items Dont group if unsure Include Items that need attention or action Tonsils? Smoking? Male? Expression At level of understanding but no more Problems with persistence, precision of coding 15
Slide notes:After the data is structured using the history and physical, then organized into meaningful groups, a problem list , shown here in the left column, can be created. A problem list is essentially the clinicians to-do list for patient care. The problem is expressed as a disease when a specific disease is known. It is expressed as a syndrome when the exact cause of the syndrome is unknown. In some cases, only symptoms or problems are listed because the clinician has insufficient information to say any more than that the patient is, for example, short of breath. Of course, the problem list evolves over time as more information becomes available; the problem list created at the first patient visit may be different from the list that exists after examination and treatment and from the list thats used with discharge of the patient. On this slide, the patients symptoms listed in the left column form the basis for a problem list. In the right column are some rules for creating problem lists. First, related items that dont need to be listed separately should be grouped if (but only if) they are part of the same process. Second, items should be included that need attention or action, but items that do not need further attention should not be included because they clutter the page and the mind. Should the tonsillectomy be recorded in the problem list? Should the patients gender or the fact that he smoked be included? Whether or not to include information depends on the context of the clinical visit. Third, each problem should be expressed at the level at which its understood and no more. To do otherwise can lead to the diagnostic error of premature closure, whereby the clinician stops pursuing a cause before really understanding it. Premature closure can lead to inappropriate diagnosis and treatment. 15