Charting on the Problem List

Still in its early stages at UCSF, one week old as of today, is inpatient documentation centered heavily around the Problem List.  This has been used by some providers in the ambulatory setting over the last year, but is now being used nearly universally on hospitalized patients.  Rather than writing an assessment and plan as free text at the bottom of an admission, progress, or consult note, each relevant item on the hospital Problem List will now have a unique assessment and plan note written specifically about that item.

This has several potential beneficial effects:

1) Sharpening a physician’s diagnostic thinking.

2) Improved continuity-of-care and ability to review a patient’s chart.  Currently, if a patient named Bob has COPD and you want to find out what has been done over the last ten years for his COPD, you have to sift back through every old note in the chart, looking for the ones where COPD was discussed.  Very time-consuming.  With the Problem List approach, Epic allows you to “View All Notes” for any given item on the Problem List.  This means that with a single click, you can conjure up every assessment and plan note written specifically about Bob’s COPD, whether from the ED, ambulatory clinic, or inpatient setting, going back through time.

We think this is a very powerful tool and are excited to see it begin to improve care.

4 thoughts on “Charting on the Problem List

    • We’ve implemented both. For the moment, the care plan remains primarily a nursing document but the rest of the team can see it. The problem list is genuinely multidisciplinary. I think the single patient-centered problem list is one of the more interesting informatics changes our go-live brought, and I’ll write more about it once we think our early experience with it has stabilized.

  1. Pingback: Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem | Wachter's World

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