VA User Manual for Problem Lists

This is from 2004 (which is apparently the mot recent version), but it is a 114 page manual for use of the problem list.  This is off of the VA website.  While a lot of it is technical, it has some great 'scenarios' describing who might be editing and managing problem lists.  I would begin reading from page 50.  I am sure we can find some other public documentation from other venders which would help us build on work already done.

I think it also discussing some functions that will generate discussion (comments to problems, categories, view lists, filters, characteristics, fields within problem lists, ect)

Here is the full document: CPRS Problem List UM.doc

Here are some excerpts:

Potential Scenarios for Problem List Entry

Outpatient Scenarios

A.  Direct data entry into the Problem List: A clinician (nurse, Physician Assistant, physician) compiles a list of patient problems relevant to the visit by direct data entry into either the CPRS GUI, the CPRS List Manager, or the Problem List package.

B.  Manual entry into encounter form: A patient checks in, is seen by a clinician, and an encounter form (usually an electronically generated form from the Integrated Billing software) is filled out by the provider. Problems addressed in the visit are captured. A purpose of visit may be recorded. The encounter form may be generic or it may be patient-specific, with ID, demographics, and Service Connection (SC) information. It may be customized to the clinic as well, with clinic, provider, and clinic-specific procedures and diagnoses. Data entry is done by a provider, who may check items or fill in free text. The provider must note which services delivered were for a service-connected condition. The provider may, in some cases, use the same form to create a progress note.

      A clerk transcribes the problem and procedure data from the form into VISTA. Free-text problem entries will be transferred to the computer to the best of the clerk’s ability. Unclear entries will be returned to the provider for clarification. A new encounter form is electronically generated from this data, to be used by the provider the next time he/she enters data for the patient.

C.  Same as above, except that after the encounter form is completed by the provider, it is scanned (through a scanning device), and entered electronically into DHCP.

Inpatient Scenarios

A. A clinician (nurse, Physician Assistant, physician) compiles the list of patient problems relevant to the hospitalization. Presently, this is mainly done by direct data entry. The potential applications of Problem List data during inpatient stays include Treatment Plans, creation of headers for Progress Notes, preparation of a prompt sheet for a discharge document, and worksheets for rounds. Problem data may benefit the Utilization Review specialist who must submit data for certification of ongoing inpatient treatment.

      Another scenario would be using the application to create a problem list (VAF 10-1415) when one is required, as for a new patient with a new chart.

B.  A clerk transcribes patient information entered by a provider on an encounter form designed to capture problem data for an inpatient. The clerk enters data from checkbox entries and free-text entries. The clerk then prints a turnaround form to allow the provider to correct errors. Clerks will record corrections and set a verification flag. (Providers may verify data online, as well.)

Back to MU element: 2011 Objective --- Maintain an up-to-date problem list of current and active diagnoses