problem list

Unknown
edited May 2016 in CDI Talk Archive
Good morning - I just finished a meeting discussing the maintenance of the "Problem List" in our work-in-progress EMR. Of course, everyone else at the meeting thought the CDI nurses should be responsible for maintaining the Problem List! I recall a discussion on CDI Talk a couple of months ago regarding the challenges of the Problem List. Has anyone out in our expansive coverage area found successful solutions to maintaining the Problem List?

Thank you, as always, I look forward to the creativity of my ACDIS colleagues.

Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com

Comments

  • kmckaigkmckaig
    edited May 2016
    In our facility, it is the nurse on the floor who is caring for the pt
    who has the responsibility of maintaining the problem list.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org


  • robert.hodges2robert.hodges2
    edited May 2016
    Our facility requires the provider to maintain the problem list. Coding did it at one time, but that practice was quickly stopped.


    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


    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
  • dbutlerdbutler
    edited May 2016
    Often a problem with an EHR. One of the keys is to sell (and demonstrate) how maintenance of the problem list makes it easier for the physician. Short term, the active problem list can be imported into the daily progress note to form the core of the A/P portion of the note. Long term, makes subsequent encounters easier. Etc.

    In 2010, U of Washington did a presentation for the ACDIS conference (In the Forms & Tools Library). They were an early adopter of the JATA Clinical Integris model and part of that workflow involved CDI input into the medical problem list.
    2010 Conference: Care Documentation as a Clinical Process
    http://www.hcpro.com/content/252239.ppt

    Personally, I would be uncomfortable with CDI managing the Problem list -- concerned about the risk of inappropriate perceptions.

    Here, nursing does conduct and record medical history as part of the comprehensive nursing history. I do believe here, Physicians do have the option of including (clicks) some, all or none of those elements into the Physician problem list.

    Don

  • tiffany_susantiffany_susan
    edited May 2016
    We did not find a solution to the problem, we did however refuse to
    populate this list as it will be a source for our coders to code from and
    should be the physicians responsibility!
    Good luck and keep us posted on how you do!

    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    phone: 570-887-6094
    fax: 570-887-5152
    email: tiffany_susan@guthrie.org
    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain






  • dbutlerdbutler
    edited May 2016
    Paul,
    Fully agree on limits of time and staffing.
    For me, there is somewhat of a local factor underlying my question as far as attention to the question. I also have concerns about potential political mine fields with CDI getting involved with those local factors.

    In the broader sense, I am considering what a generic (ie, not focused on specific cases) message to support clinicians on ways for them to double check problem list population that will also help with CDI areas of interest -- a more complete and codable record. A concern I do have is that though we may get a more complete problem list (that in an EMR often is incorporated and drives daily progress notes), that same problem list may well have all of the issues regards specificity and detail.

    This is also a topic that makes me think of Glen Kraus -- with his encouragement to CDS's to expand their focus and perspective. Seems to fall in line with that perspective. Something in the longer view we all ought to be thinking of.

    And by the way, I always enjoy your insights and contributions to the conversations around here.

    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    PCMH, Greenville NC
    dbutler@pcmh.com


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Don - thanks, I enjoy your messages, as well. I most definitely do see
    how a valid and complete Problem List will enhance data quality for all.
    As you stated, the issue is time. Our CDI department works in the
    Quality Department, which is a big PLUS, I think. Sometimes we are
    asked to perform other audits not 'directly' relating to inpatient
    coding. The issue becomes 'time' and missed opportunity costs, but
    we also must keep the big picture in mind.

    We don't have the EHR yet, but from what I am reading, accurate
    maintenance of a valid and active problem list is a challenge.

    Paul

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • sbeattysbeatty
    I hate to sound like an advertisement for 3M's CDIS product, but the embedded encoder allows us to print out the list of codes we've assigned to date. We put a copy in the chart for the physician to refer to when they do their daily progress notes and the DCS. We educated them that this is a running list of what has been documented and treated to date. If something gets ruled out, or added, we rerun the list and replace it. Our hospitalists have found it helpful, especially when patients come out of ICU and have had a prolonged LOS. It allows them to have a synopsis of what's been treated to date and diagnoses that were treated and are now resolved or ruled out. It also pulls together all of the consultants diagnoses for the attending to determine whether to include in the DCS or not. We currently have all of our MD documentation on paper, and are implementing an EMR next June. It will have a problem list and we are anxious to see what the impact is going to be on our work flow, as well as how it populates and the level of accuracy from a CDI standpoint.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes! I have brought this issue up before. Definitely the true problem list should be maintained by the MD. There has been discussion in our facility that CDI maintain a diagnosis list in the EMR that the MD then can 'verify dx' from that list and it automatically then moved the verified dx into their problem list. This is a function currently available in the EMR and nurses (on the floor) already do this at our facility. I think even this is grey and only acceptable if we are only putting dx in the list that have already documented in the record by an MD.

    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
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    The same discussion is happening in our facility. Unless we can find evidence stating this against our nurse practice act or evidence to show there is conflict of interest we are going to have to do a trial of this with a small group of physicians. There is a thread in CDI talk from about a month ago with the same topic as I had posted about this topic then.
    Cindy
  • lindenbm@bellsouth.netlindenbm@bellsouth.net
    edited May 2016
    Thank you Cindy and Katy for your input. We are having a meeting next week regarding this. I am concerned about my scope of practice as a licensed RN regarding maintaining a patient problem list.


    Mary Lindenboom, RN, BSN, CCDS
    Clinical Documentation Specialist
    Flagler Hospital
    400 Health Park Blvd.
    St. Augustine, FL  32086
    (904) 819-4254
  • Unknown
    edited May 2016
    I think it is a big no-no. Let the Physicians and Nurse Practitioners do their jobs. I have enough to do just trying to improve their documentation.

    Mary L. Snook RN-BC
    Clinical Documentation Specialist
    Medical Information Services
  • Unknown
    edited May 2016
    I think it is nothing but trouble! Having survived the transition to having Nurse Practitioners and knowing what they can and cannot do I would refuse. Our scope of practice is very defined. We cannot diagnose!

    Mary L. Snook RN-BC
    Clinical Documentation Specialist
    Medical Information Services/Fairfield Medical Center in Lancaster, Ohio 43130
    740-689-4443
  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    For us we would be putting in the diagnosis after the query and the MD would be responsible for signing the problem list.
    c
  • kshumpertkshumpert
    edited May 2016
    I do not add to the problem list. Our nurses can add to the problem list. Nursing documentation flows to our problem list when they record the PMH. Physicians can always amend the diagnosis added.

    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
  • cindy.pritchett04cindy.pritchett04
    edited May 2016
    I agree that the problem list should be "owned" by the physician. As a
    traveler, the most recent organization I worked with was in the process of
    developing a P&P/protocol specifying that the physician "owned" the problem
    list, thereby making it eleigible to code dx from. That sounds like "best
    practice" to me. Of course - this is dependent on the respective EMR and
    internal processes of the facility.
  • paxnerospaxneros
    edited May 2016
    We have been working a "Meaningful Use" Report for quite sometime. I was not for this - for one it increases the workload on an already overloaded staff. Coding actually had picked this up and I never thought they should be performing the task either.

    Someone mentioned a JCAHO Standard or requirement? I would love to have the reference! Perhaps this can be some authority to abandon this task!

    Thank you,

    Norma T. Brunson,BS,RHIA,CDIP,CCS,CCDS
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We have the ability in our EMR (cerner) to have a 'problem list' that is managed by the RN that then the MD has to verify each 'problem' to move it to a 'Diagnosis List'. Then this Diagnosis list can be autopopulated into their note.
    Occasionally it has been suggested that CDI should manage this list. It’s a complex issue and one I personally would prefer to avoid but I realize this may not always be an option.
    Things to think about if CDI will manage this list are:
    1. CDI must only include problems that are already documented in the record. We cannot be using the problem list as a way to circumvent the need for queries. We are held to a different standard than the floor nurses. They may be able to see clinical indicators of PNA in the record and suggest this dx for the problem list. We cannot.
    2. Does your CDI program review all inpatients? I know it is our goal that ALL patients have a electronic problem list (I believe this is part of 'meaningful use'). If CDI only reviews a portion of the records it does not make sense to have them responsible for the list in my opinion. It seems this would cause a lot of confusion as everyone would need to know which cases are being reviewed so that the problem list would be completed for all patients. It would make the most sense to have one group responsible for all problem lists. We have recently moved to reviewing all inpatients so I am waiting for this to come up again.

    I am sure there is more, but that’s what's at the top of my list.

    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
  • lindenbm@bellsouth.netlindenbm@bellsouth.net
    edited May 2016
    Thank you Katy. I agree with you on all fronts. IT is trying to come up with a way that when a query is answered it would go to the problem list. And of course, if they want CDI to see 100% of all patient's, we will definitely need more CDI's.

    Again, thank you.
    Mary
  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Actually at our facility, we have a list of previously diagnosed conditions which auto populates in Meditech based on final coding. I recently took a survey of how many of our physicians were using this tool and it was extremely high. They found that this list of problems assisted them in admitting their patients.
    We do not create this nor do we help to formulate the list. It comes directly from our software.
    Thank you
    Lisa



    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    804-228-6527
    Angelisa.Romanello@HCAHealthcare.com
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