A simple approach to physician entry of patient problem list.

Abstract

The patient's problem list is one of the key components of the electronic medical record. Besides the immediate benefits of using the patient problem list for medical records coding and creation of discharge documentation, a coded problem list is a prerequisite of patient management, clinical decision support and research. The ICD9 coding system that is the current standard for coding diagnoses and procedures is not conducive to physician usage. In this paper we describe a simple system that provides physicians with a quick and easy method to enter and maintain a patient's problem list. Physicians can use their own terminology. ICD9 codes are included where possible, but free text is allowed. The system strikes a balance between capturing a fully coded patient problem list and encouraging usage by a wide physician user group.