By Dr. A. Carbonell
The problem list will need to be created for every new patient. When you encounter the new patient visit you will be prompted to add the diagnoses under the diagnosis tab. Be sure to select all of your problems (Press the control button on the keyboard and select all of the problems) then click on “add to problem list” button next to the list. You will then be prompted to select the appropriate SnoMed Code for the problem to be added to the problem list. You DO have to type the problem again for find the snomed code.
ESTABLISHED PATIENTS
At subsequent encounters you can select the problems from the already pre-completed problem list under the diagnosis tab when you are encountering your visit. However, if you would like to add a new problem you can select a problem from the PC COMMON DIAGNOSIS list or click on the “other diagnosis” button to add a diagnosis. If you would like that problem to be added to the problem list make sure to highlight that problem then click the “add to problem list” button next to the list, this will prompt you to find the appropriate SNOMED code for the problem and once selected this will populate into the problem list.
CAN YOU CHANGE THE PROBLEM LIST WHEN THE PATIENT DOES NOT HAVE A VISIT?
YES! If you are under an administrative encounter (reviewing outside medical records, reviewing labs, etc.) You can go to the tab titled “problems” on the bottom left of the screen and click “New Problem” - the most common primary care problems will auto populate on the left side of the list, however if your problem is not on their list click “other problem” and add it manually.
CAN I REMOVE A PROBLEM THAT IS NO LONGER RELEVANT?
YES! Go to the problem list (problems tab) and select the problem that you would like to remove. Right click the problem and select remove, this will take it you to a screen where you can then click remove and the problem will be removed from the patient’s problem list.