Problems with problem lists

catladyrn

What do you do when the diagnoses on the problem list don't match the diagnoses included in the physician narrative? I've run into multiple issues, such as the initial impression being put on the problem list, the workup changing the impression in the progress notes, but the problem list not being updated. Or physicians switch off and the new doc uses a different or less specific diagnosis; the problem list says acute kidney injury and the progress note says acute renal insufficiency. Problem list says encephalopathy and the progress note says delirium. Etc. On occasion I've sent a query asking to clarify the status of the diagnosis on the problem list, but it's an awkward query. Do you just accept the existing problem list as being the definitive list of diagnoses?

Thx,
Renee

Linda Renee Brown, RN, CCDS, CCS, CDIP

fishdl@shands.ufl.edu

A related issue... Because the problem lists are so unreliable, our coders have been told they cannot assign codes based solely upon diagnoses documented on the problem list. In fact, if a diagnosis is documented on the problem list that is not also documented elsewhere, and is not supported by diagnostics and/or treatment (i.e. pneumonia documented without signs/symptoms/clinical evidence/treatment), we can 'ignore it' and are not obligated to query for clarification.
We've discussed the issue with our physicians, however, they are reluctant to remove or document as resolved, a diagnosis entered by another provider.
This is a source of frustration for all of us...

Donna Fisher, CCS, CCDS
fishdl@shands.ufl.edu

kbenson@uwhealth.org

We have the same issues. Getting everyone on the same page regarding the problem list is on my wish list!

Kathleen Benson RN, BSN, CCDS
Supervisor, Clinical Documentation Integrity
University of Wisconsin Hospital
kbenson@uwhealth.org

catladyrn

Thanks for the responses thus far.

Another huge issue that I neglected to mention: the docs paste the active problem list into their note, but then the narrative contradicts or shifts what's on the problem list, or, worse, ignores the so-called problem altogether. Coding then takes the problem list diagnosis because it's technically in the progress note. So for example, you have an initial impression of sepsis, added to the problem list at the time of admission; the workup goes in a completely different direction and sepsis is never mentioned again, but because the unedited problem list is pasted into the progress notes every day, the principal diagnosis is coded to sepsis.

I like Robert's query, but I still am racking my brain to come up with a polite yet concise and effective way of asking them to keep the problem list and the narrative in line.

Renee

Linda Renee Brown, RN, CCDS, CCS, CDIP

evanspx@sutterhealth.org

Problem lists are very often totally inaccurate, as they do not reflect the valid acute conditions being treated during the episode of care, nor do they contain with much accuracy valid conditions that should be coded for ROM/SOI. IMO, no coder should 'use' a problem list to code, but should confirm every condition stated qualifies for reporting.

I DO briefly review a problem list to try to obtain the Medical-Decision Making process for the MD staff - but, I know of no coder that considers the problem list a valid source for official coding purposes.



Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002

evanspx@sutterhealth.org