Problem List in Encounters

The Problems section in the Limited, Comprehensive, PD, HHD, and AKI Encounter notes allows you to add active problems to the encounter.  New problems can be added, and existing problems can be edited, removed, or resolved within the encounter note. 

Click the blue plus sign for Add Active Problem(s), and the patient's current problems are displayed in a collapsed form indicated by a horizontal arrow (>).  The displayed problem data includes the problem name, SNOMED (Systematized Nomenclature of Medicine) code, ICD-10 code, added or updated date, and the user who added or updated the problem. 

Click the arrow to expand the problem data to view the reported date, onset date, onset info, managing provider, and problem comments, if available.  Problems marked as a priority are displayed at the top of the list with an orange star.  The most recently added priority problem will show first if there is more than one priority problem.

To add an active problem to the note:

STEP 1: Click the Add Active Problem(s) blue plus sign

STEP 2: Select problem(s) to add to the note

NOTE: Click Select All to include all the patient's problems, or individually click each problem.

STEP 3: Click the DONE button

NOTE: Problems can be removed from the note by clicking the Add Active Problem(s) icon again and unselecting the problem.

To add a problem to the problem list:

STEP 1: Click the Add New Problem blue plus icon

STEP 2: Begin typing a problem name to search and then select from the populated list

STEP 3: Enter the appropriate problem details

NOTE: Reported Date, Source, and Status are required fields. 

STEP 4: Click the SAVE button

NOTE: Click SAVE &CREATE NEW to save the current problem and create a new one. 

To edit a problem:

STEP 1: Click the Edit icon next to the appropriate problem

STEP 2: Edit the appropriate fields

NOTE: All fields except the problem name and associated SNOMED and ICD-10 codes can be modified.

STEP 3: Click the SAVE button

To resolve a problem:

STEP 1: Click the Remove icon next to the appropriate problem

STEP 2: Select Resolved as the clinical status

STEP 3: Enter the resolved date and comments if needed

STEP 4: Click the UPDATE button

To delete a problem:

STEP 1: Click the Remove icon next to the appropriate problem

STEP 2: Select the appropriate clinical status

NOTE: The original author is the only user who can permanently remove the problem by choosing the "Entered In Error" option. A problem that a clinician enters in CWOW that the provider deems inaccurate may be deleted in OneView. Clinicians may not delete problems that a provider creates.

STEP 3: Click the DELETE button

Problems resolved or deleted are moved from the "Current" list to the "Resolved/Deleted" list, and the priority is removed.

To manage problems in future encounters:

STEP 1: Slide the Keep in Notes toggle next to the appropriate problem

NOTE: When toggled, the problem appears on all future notes.  At any point, the Keep in Notes toggle can be turned off so the problem will not display in future encounters.

Problems added to the note appear on the encounter PDF under the Problems section.

Content on this site is for informational purposes only and does not represent actual patient data.