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Controlled vocabulary for problem lists may be contained in a problem list directory master table.Of note in this standard is the reference to past diagnoses and social care factors.Other factors such as social problems, psychiatric problems, risk factors, allergies, reactions to drugs or foods, behavioral problems, or other health alerts may be included.The standard also notes that the problem list should be amended as more precise definitions of problems become available.Some standards to consider when developing problem list policies and guidance are outlined below.Organizations surveyed under the Joint Commission's Hospital Accreditation Standard (RC.) are required to initiate a summary list for patients by the third visit.They are an important communication vehicle used throughout the entire healthcare continuum.
The standard requires that the presence or absence of allergies and untoward reactions to drugs and materials be recorded in a prominent and consistent location in all clinical records.If the functionality for adding and removing active problems is difficult or awkward to accomplish, the list can become overwhelming and unreliable as a current data source.This practice brief reviews applicable standards for problem list content, examines the role of the problem list in the EHR, and provides guidance on managing problem lists.This information must be verified at each patient encounter and updated whenever new allergies or sensitivities are identified.The Healthcare Information Technology Standards Panel convened stakeholder meetings between 20 to advance interoperability and EHR adoption.
Adopting existing national standards is critical to achieving complete, consistent, and quality data, as well as working toward the future of healthcare data exchange.