Dream Factory by TruBridge Ideas Portal
Providers do not keep up on the Problem List (of course we try to enforce this but it is a loosing battle). Our coders add problems via their documentation into the record, but there is no communication to the Problem List. At the least the primary diagnosis should add to the problem list after being coded. The other issue is that dates and status are not required fields and they are constantly left blank. Correct and up to date information is so important for continuity of care. Finally, problems imported from CCDA documents do not carry in status, date OR provider, all very important; in hospital, I cannot possible know dates or providers from the outpatient setting.
I have included an attachment showing coded diagnoses and problem list for a (the same) patient (no identifiers included). It is pretty relevant to future care for clinicians to know the patient was diagnosed with acute gastritis with bleeding and the date vs the descriptive problems of RUQ pain, nausea, diarrhea, and chronic cholecystitis from the problem list.
Status update?
Agree there are a lot of issues with the Problem List. If something is on the Problem List and that code expires, nothing stops anyone from still attaching said problem to an account after it was expired. And using descriptions to select problems poses the issue of having multiple "descriptions" having the exact same ICD10 code... causing claims to deny.
There are a lot of other problems with the Problem List other than the above. If something was entered in error it should just be off of a patient's list all together and not show up when All Problems is selected. The biggest problem is when a provider actually does try to put in a dx. They seldom pick the correct code which then has to be marked entered in error and then the correct code is put in by the coder. The description on some of these codes is way off. Example: Provider put in description painful enlarged lymph nodes and gets a choice to pick R52, pain unspecified, which will not cover the US of the lymph nodes. Through query, provider wanted R59.0 localized enlarged lymph nodes. The description lists can be long and providers do not pay attention to what code they are choosing. It would be best to just allow them to free type a diagnosis and let the coders choose the codes. That is another whole issue on its own.
But dates and taking off entered in error off the charts is a big thing!