Problem lists?

katysuegood@gmail.com

For those with EMR’s in place. Have you considered or do you help manage the problem list in the EMR? We use Cerner and there is the option for a problem list to be populated by a nurse with dx then verified by the MD and moved into a true problem list that is then populated into the Progress note template (PowerNote). We are not currently using this feature but they are planning to eventually.
I am curious whether CDI’s are involved in this process at other facilities and what the ethical implications would be.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

robert.hodges2

Absolutely not. Before I arrived coders were allowed to update the problem list based on the diagnoses coded for the encounter but this process stopped. The reason being, or so I'm told, is that only the provider can or should determine if a problem should be on the patient's problem list and they are also responsible for maintaining and updating the list.



That's just one perspective, but we have a fully integrated EHR here and have had for many years.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)

VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated



"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

kshumpert

Good morning. We have Cerner as well. Our problem list is populated by nursing and the physicians pull the appropriate problems into their powernote. I am fine with this functionality. The problem list is reviewed by the physician. This function is no different than a nurse writing the past medical history on their nursing assessment form. I created a list of the 50 most common problems and saved the unspecified diagnosis in a folder for nursing. This was to help save time for nursing. I don’t think there is anything unethical to have a nurse document a patient’s history, further, I think that if appropriate, the physician should be able to use the same information. Why should we have to double document? I do not add anything to the problem list as I feel that could be a conflict. I do serve on a physician champion team that helps to make decisions for our use with Cerner.

Thanks,
Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46902
Office 765-864-8754
Cell 765-431-0123
Fax 765-453-8447

katysuegood@gmail.com

I want to clarify how this works in Cerner. The MD is the only one allowed to truly maintain the Problem list. However, there is a section where a nurse may choose perspective dx for their own problem list. In order for these to then make it onto the MDs list, he/she would have to ‘verify’ the nurses dx.
We have an issue with dx ‘falling off’ progress notes and there is the suggestion that using the ‘problem list’ function would help. We have not been asked to manage the nursing portion YET, I am just trying to figure out my stance. Clearly, I don’t believe we could add anything that was not already stated in the record. I think the question is whether once a dx was documented, could the CDI then move this into the nursing problem list for the MD to verify?

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

robert.hodges2

So this would either augment or replace your query process? As a floor nurse would they then have to add a nursing diagnosis to the medical condition the CDI would add since this is subject to audit during a credentialing survey?



Of course you also have the question of whether or not the physicians will read the nursing problem list.



Just thinking out loud here. Personally, I would avoid it but I have the advantage that my queries are, by directive, not to be part of the health record.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)

VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated



"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

katysuegood@gmail.com

It would not replace it because I (personally) do not feel like we would be able to suggest dx that were not already in the record. For ex: if the MD documents CHF, we could not then look at the ECHO and include “acute on chronic systolic CHF” on our problem list. We would only be able to include “CHF”, query on it and update it in the problem list when the query was answered. It would only ensure that diagnosis are carried through to discharge and provide the MD with a list of what dx we have pulled out from their documentation.
We have not started this process with the MD’s but the nurses are begin to use the list for hx. The lists are housed on the same screen and the MD just reviews their list and verifies whichever dx they believe applies. So I think they would use it, if they were required to use the problem list function.

I appreciate everyone’s thoughts. I like to think the implications of these things through BEFORE someone asks me to take on a new process ☺

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

cstukenberg

What about problem lists that have the ICD code already attached to the diagnosis. Ie. CHF 428.0. If there is a discrepancy in diagnosis, is this a problem?
Scenario:
The patient is admitted with COPD and also has acute CHF. The physician chooses the exac of COPD 491.21 but only chooses the basic CHF diagnosis 428 on the problem list.
He later documents that it is acute systolic CHF but never updates the problem list to 428.21.
Then the coders code the chart as a COPD exac 491.21 with acute systolic CHF 428.21 (DRG 190) because the documentation is there.
However because the problem list is not updated with the acute systolic CHF and only has the basic CHF on the list a reviewer says it should be a drg 192 (no MCC).

Is it a problem that the physician does not pick the correct diagnosis on the problem list?

As we move forth in ICD 10 and the codes will become even more complex I think it will be an issue that what the physician chooses for the codes/diagnoses on the problem list does not match what the coders end up coding the final chart.

Any thoughts? I would prefer not to have the codes even show and just have the physician document and the coders code.

cstukenberg

What are your thoughts of the situation if your system worked the way I described.

Unknown

I have been reading this thread and find myself needing to jump in. The management of the problem list is strictly a physician responsibility, requiring the clinical judgment and medical decision-making of the physician. The problem list is designed and intended to be a communication tool between physicians and other non-physician practitioners in the inpatient and outpatient setting, primarily focusing on ongoing chronic conditions under active management. The problem serves strictly as a communication tool between providers, not intended to be used as a source of documentation necessarily for acute conditions and certainly not intended for documentation that facilitates coding and reimbursement. I refer you to the Coding Clinic First Quarter 2012 page 6 for an excellent discussion on the electronic health record and the use of drop down boxes with ICD-9 codes. In summary, the Coding Clinic states it is not appropriate for providers to list the code number or select a code number or select a code number from a list of codes in place of written diagnostic statement. ICD-9-CM is a statistical classification per se, it is not a diagnosis.

 

Having said this, our focus as CDIS should rightfully be complete and accurate clinical documentation throughout the record to support quality outcomes, risk or morbidity and mortality, readmission risk, and efficiencies in the delivery of medicine. The process is true clinical documentation improvement and the byproduct and outcome is accurate reimbursement. Monkeying around with the problem list as a means of populating the progress notes with potentially inappropriate clinical diagnoses that then becomes a source of ICD-9 coding is a dangerous practice, we already see useless cut and paste and carry forward documentation that detracts from the quality of documentation, often times representing a bunch of noise with no substance.

 

Take home message, recognize the intent of the problem list, a communication tool and not a reimbursement tool. Leave the management of the problem list to the responsible party, that is the physician.

 

Thank you

cstukenberg

I agree that it should be a tool for communication that flows between the inpt and outpt world, however the problem list in computer programs may be linked to the ICD codes which are attached to billing, reimbursement, etc. So the issue is not per se the idea of the communication with the problem list as much as the code is attached which goes other places. This can be a nightmare for the patient when the incorrect code is chosen by the provider because they are not coders and do not know the coding rules. I would prefer the problem list to be a list of diagnoses the physician can chose from without the codes attached. Unfortunately when computer programs do not work that way, we need to figure out how to deal with the accuracy of codes/diagnoses that end up on that list.
Any thoughts how to handle that besides telling the computer vendor to change their program since that does not happen easily….?

laura.bohls@prairielakes.com

There has been an idea thrown out at our facility to have the problem list populated by the computer system by inserting the diagnosis from when the coders code the chart after discharge. What are anyone’s thoughts on that process. Thanks

Laura Bohls, RN CDS
Prairie Lakes Hospital
Watertown, SD 57201

robert.hodges2

As I stated earlier in this thread that coders adding to the problem list based on coded diagnoses used to be the process here but was immediately shot down when the new HIM Chief arrived for all the reasons that have been stated before. The provider is responsible for maintaining the patient problem list to enhance continuity of care. If providers are unwilling to do this then other actions should be considered by a healthcare organizations leadership to address this.



This is just my personal opinion (and does not reflect the opinions of the Department of Veterans Affairs, the Veterans Health Administration, or the Aleda E. Lutz VA Medical Center – yes the disclaimer is needed) but we tend to coddle doctors a lot because they are the source of revenue for a hospital. But I then ask if we do this and allow providers with poor documentation, poor resource utilization, or poor professional habits to continue to have privileges because they admit a lot of patients and/or perform a lot of procedures are we doing the patient and the facility more harm than good? While the bottom line is a reality there are things far more important than that including quality of care.



OK, now I’m off my soap box. Back to the work of the day.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)

VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated



"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

katysuegood@gmail.com

Right. I JUST asked this question yesterday. “what are the implications when the MD chooses a specific CODE in their documentation and the coder chooses a alternate code based on the actual narrative in the documentation? Do we know if this is going to become an issue with insurers/denials/etc?”.

But let me clarify again, in the Cerner system ONLY the MD can maintain the actual problem list. However, there is a system set up whereby nurses input perspective dx into their own progress note that can then verified by the MD. This is primarily for inclusion of past medical history, etc. If the MD verifies the dx, it moved onto their problem list. Additionally, I would absolutely think it unethical for a CDI to enter in dx to the nursing problem list that have not been documented. The question is, if the MD documents a dx (ex: ARF with ATN), could the CDI then add that dx to the nursing problem list for verification? The purpose being to insure that the specificity is included throughout the record.

I’m crossing my fingers that this doesn’t even become a suggestion but I imagine someone will bring it up eventually and I hope to be prepared.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404