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Problems in the Encounter Note

Updated
Cortnie Sproul
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The Problems section in the Comprehensive, Limited, 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. 

 Encounter-Problems.png

Viewing Patient Problems in the Note

Click the blue plus sign for Add Active Problem(s), and the patient's current problems are displayed in a collapsed form.

 

Click the arrow (>) to expand the details for each problem.

 

The data displayed by default 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. 

 Encounter-Problems-expand.gif

The expanded view lists the reported date, onset date, onset info, managing provider, and problem comments, if available. 

Problems Designated as Priority

Problems marked as a priority are displayed at the top of the list with an orange star. 

 Encounter-Problem-PriorityStar.png

The most recently added priority problem will show first if there is more than one priority problem.

Steps to Add Active Problems to the Note

Click here to view the steps


  1. Click the Add Active Problem(s) blue plus sign
 Encounters-AddActiveProblem.png
  1. Select the applicable problem(s) by clicking Select All or individually clicking each problem
 Encounters-AddActiveProblem-select.png
  1. Click the DONE button
 Encounters-AddActiveProblem-done.png

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

Steps to Add a Problem to the Problem List

Click here to view the steps

  1. Click the Add New Problem blue plus icon
 Encounter-Problem-New.png
  1. Begin typing a problem name to search and then select from the populated list
 Encounter-Problem-Search.png
  1. Enter the appropriate problem details

 

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

 Encounter-Problem-Details.png
  1. Click the SAVE button or click SAVE & CREATE NEW to save the current problem and create a new one.
 Encounter-Problem-Save.png

Steps to Edit a Problem Added in the Note

Click here to view the steps

  1. Click the Edit icon next to the appropriate problem
 Encounter-Problem-Edit.png
  1. Edit the appropriate fields
 NOTE: All fields except the problem name, associated SNOMED and ICD-10 codes can be modified.
  1. Click the SAVE button
 Encounter-Problem-Edit-Save.png

Steps to Resolve a Patient Problem

Click here to view the steps

  1. Click the Remove icon next to the appropriate problem
 Encounter-Problems-Remove.png
  1. Select Resolved as the clinical status
 Encounter-Problems-Remove-Resolved.png
  1. Enter the Resolved Date and Comments, if needed
 Encounter-Problems-Remove-ResolvedDate.png
  1. Click the UPDATE button
 Encounter-Problems-Remove-Update.png

Steps to Delete a Patient Problem:

Click here to view the steps

  1. Click the Remove icon next to the appropriate problem
 Encounter-Problems-Remove.png
  1. Select Entered in Error as the 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.

 Encounter-Problems-EnteredInError.png
  1. Click the DELETE button

 

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

 Encounter-Problems-Delete.png

Managing Problems in Future Encounters

To ensure a problem is documented in all future encounter notes, select the Keep in Notes toggle next to the appropriate problem. Encounter-Problems-KeepInNote.png

NOTE: When turned on, 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 in the Encounter PDF

Problems added to the note appear in the PDF version of the encounter available through the Clinical Summary section of the chart.

Encounter-Problems-ProblemsinPDF.png

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

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