Diagnoses and Problems Lists
The iPATH team continues to work with clinicians to make the Diagnoses and Problems List more
user friendly. The information below addresses some issues that the team is working to improve. The
Problem & Diagnosis List should be managed by all medical staff (physicians, non-physician
providers (PA-C, FNP, NP, etc)) caring for the patient.
Impact if the list is not managed:
 Conflicting, duplicative or erroneous diagnosis and problem information impacts coding, billing,
future care providers, and viewers of the patient portal. Providers should review/update the
lists throughout the encounter following guidelines in table below. Diagnoses and problems
should be canceled, inactivated, resolved, and removed as appropriate.
 To view a 3 minute video on how to manage Diagnoses and Problems, please visit
http://www.munsonhealthcare.org/problemsanddiagnoses.
Diagnosis This Visit - Diagnoses are
associated with a particular patient
encounter.
o
o
o
o
o
o
Conditions that are the reason for the
patient’s visit, which may also appear on
the patient’s problem list.
An acute symptom while under active
evaluation for a diagnosis, e.g., headache
or abdominal pain. Once a diagnosis has
been made, it should be replaced on the
Diagnosis List as a replacement for the
symptom.
Acute minor problems that will likely
resolve by the next visit, e.g., URI, minor
rash, strep throat.
Symptoms, unless the symptom is chronic,
and a diagnosis has not yet been made,
e.g. “chest pain” should be replaced by
“angina pectoris.”
Conditions that develop during the course
of the hospitalization and require
evaluation, treatment, monitoring, or
increase the length of stay.
DO NOT include resolved chronic
problems or conditions from the patient’s
past medical history that are no longer
under treatment or have no bearing on the
current hospitalization.
Problems Active Across Encounters The problem list is associated with and
linked to a patient's medical record
number, and crosses encounters.
o
o
o
o
o
o
o
o
o
o
Conditions that extend across encounters,
which are usually chronic (e.g., diabetes,
hypertension, etc.).
Any condition requiring the ongoing use of
scheduled or ordered PRN medications.
Medical conditions requiring frequent
laboratory testing for monitoring purposes.
Chronic medical conditions that require
continued treatment, screening or
monitoring.
Recurring acute medical conditions
requiring evaluation or treatment such as
recurrent urinary tract infections.
An old problem not requiring current
treatment which still influences current
treatment decisions for other problems,
e.g. a History of DVT.
Active or relapsing chemical dependency
or abuse (including tobacco).
Positive screening tests that will have an
impact on continuing care or disease risk.
Entries to record some permanent post–
operative conditions such as prosthetics,
implanted equipment, important new
anatomy.
DO NOT include resolved chronic
problems or conditions from the patient’s
past medical history that are no longer
under treatment or have no bearing on the
current hospitalization.
Diagnoses and Problems Lists
Additional Documentation Tips:
 The combination of the Diagnoses and Problems should equate to what was previously known
as the “Final Diagnosis”. It may be appropriate to have a condition exist as both a problem and
a diagnosis. For example, a patient with COPD admitted with an acute exacerbation could
have COPD listed as an active problem and COPD acute exacerbation as a Diagnosis. If the
patient was admitted for treatment of another condition and COPD was not exacerbated,
COPD would only be listed as Problem. (Duplication of items within problem or diagnosis list
itself should be avoided.)
Dx
Px
Final
Diagnoses
 Problems and Diagnoses should be as specific as possible. The Hospital Course section
should be used to link diagnoses that are related, e.g. Type 2 AMI due to atrial fibrillation.
Diagnosis- This Visit and Problems- Active Across Encounters, as well as Discharge
Medications, are dynamic elements of the Hospital Summary. Whenever a change is made to the
Medication List or the Problems and Diagnosis (Consolidated Problems), use of Final/Distribute on
the Hospital Summary will show new information EVEN IF THE CHANGE IS MADE FOR A
DIFFERENT PATIENT ENCOUNTER.
Implications:
 Changes made to the Problem and Diagnosis List or the Medication List after discharge may
result in an erroneous Hospital Summary if the Hospital Summary is Finalized after the
changes are made.
 If a patient is readmitted before the Hospital Summary is Finalized for the previous encounter,
changes made for the readmission encounter will appear on the previous encounter Hospital
Summary.
 Best practice is to complete any CDI queries prior to discharge AND Finalize/Distribute
the complete Hospital Summary at the time of discharge.
How to manage post-discharge diagnosis updates:
Should a diagnosis need to be added or require greater specificity to properly reflect the
circumstances of a patient encounter, the appropriate provider will be notified via a bright green query
form in the physical chart available in the Health Information Management Department.
Answer the query with the diagnosis information and indicate your preference for updating the
record. Transcription will prepare a Final Diagnosis addendum to the Hospital Course based on
what is written on the query form or you may dictate the update and an addendum will be
transcribed. Both will be available for electronic signature by the attending physician.
Diagnoses and Problems Lists
Improvements coming soon:
 Currently, the Problems and Diagnoses (Consolidated Problems) search looks for and displays
a “clinician friendly term”, while coding terminology to which the term is mapped is printed on
the Hospital Summary. In the very near future, “clinician friendly terms” will list on the Hospital
Summary; thus eliminating any display differences between the Consolidated Problems list
and the Hospital Summary.
 After this change occurs, clinicians must utilize the Consolidated Problems component of the
Discharge MPage to search for a specific diagnosis using the ICD-9 code number. Searching
from the Problems and Diagnosis tab will allow clinicians to search by term only, not number.