A SIMPLE APPROACH TO PHYSICIAN ENTRY OF PATIENT PROBLEM LIST

The patient's problem list is one of the key components of the electro nic medical record. Besides the immediate benefits of using the patien t problem list for medical records coding and creation of discharge do cumentation, a coded problem list is a prerequisite of patient managem ent, clinical decision support and research. The ICD9 coding system th at is the current standard for coding diagnoses and procedures is not conducive to physician usage. In this paper we describe a simple syste m that provides physicians with a quick and easy method to enter and m aintain a patient's problem list. Physicians can use their own termino logy. ICD9 codes are included where possible, but free text is allowed . The system strikes a balance between capturing a fully coded patient problem list and encouraging usage by a wide physician user group.