patient problem list Flashcards
patient problem list
section of chart that helps organize the patient’s history and allows doctor to identify patient active issues quickly
what does a patient problem list include
all active and resolved conditions (diagnoses or symptoms)
how are diagnoses and symptoms organized on a patient problem list
active and most concerning at top
what is included in patient problem list
chronic illnesses, surgeries or procedures, injuries, symptoms and diseases
differences between PMHx, PSHx, and patient problem list?
statuses are NOT included in PMHx and PSHx, active and resolved statuses are listed in patient problem list to help doctor identify most relevant symptoms
what info is included? which are mandatory and which are optional
diagnosis - mandatory, status - mandatory. optional: notes, onset date and resolved date
Father had NIDDM. Is this information included in patient problem list? Why or why not
no, FHx is not included, only symptoms involving patient themselves
Patient is a smoker. Is this included in the patient problem list
No. SHx is not a specific illness or problem.
Patient got a knee operation. Is this listed on the patient problem list?
Yes. Illnesses, surgeries, injuries are all included, not FHx, SHx.
How are statuses listed in the patient problem list?
active or resolved, depending on if the issue is still ongoing or not. Chronic issues always active
How are problems ranked on the problem list?
active on top, resolved on bottom, higher risk at top, lower risk at bottom.
A healthy patient with no PMHx will be documented as what in the patient problem list
Active - No Known Problems
What kind of optional notes are useful in a patient problem list?
how its controlled, medication, non-pharmalogical, how its monitored, evaluated
what should not be documented on onset or notes
side, severity, often can just find a better disease documentation
54 y/o male with CAD, MI in 2013. HTN controlled with medication, diet, exercise. Previous knee injury resolved. List the patient problem list.
- Active, Coronary arteriosclerosis in patient with history of previous myocardial infarction. Onset 2013. 2. Active, HTN, Primary, note controlled with meds diet, exercise, 3. Resolved, Myocardial infarction, onset 2013, 4. Resolved, Knee injury, left, problem note occured a few years ago, onset unknown
