If you have an electronic health record (EHR), you are familiar with the problem list — the list of conditions that have been associated with each patient at some point in time. At its best, the problem list gives a quick and easy-to-understand summary of the patient. If it's not up to date, however, the problem list can become so unwieldy it's not useful or, worse, it's deceptive.

Keeping problem lists orderly is more complicated if you work for a large organization with multiple specialties that share the lists. It requires the entire team; but as primary care physicians (PCPs) and “captains of the ship,” we often have ultimate control over — and therefore responsibility for — the list.

There is no single way to organize a problem list, and no national consensus about it in the U.S., although there is in some other countries.¹ Therefore, in many organizations, the problem list is a catch-all for capturing visit problems, symptoms, past medical history, family history, allergies, etc. In this article, we focus on using the problem list for only chronic conditions and recurrent acute problems considered important for patient care, and we present some principles to help you organize your lists.

WHAT A PROBLEM LIST SHOULD BE

The problem list is a shortcut to understanding the patient. It should be a quick, useful reference describing who the patient is medically. To remain useful, the problem list must be a “living document” that changes as the patient's condition changes. Problem lists should only include active problems and issues relevant to present and future care. This requires removing problems that are no longer relevant and adding newly diagnosed chronic conditions.

In most EHRs, the problem list is used for clinical decision support. For example, if diabetes and chronic obstructive pulmonary disease are on the problem list, the EHR may remind the clinician to order a microalbumin or a pneumonia vaccination. If some entries on the list are inaccurate or obsolete, it becomes harder to zero in on what the patient really needs.

When a condition is no longer active but affects the future management of a patient, a PCP can keep it on the list but give it a “History of” designation. For example, a patient diagnosed with deep vein thrombosis (DVT) gets “DVT” on their problem list. When DVT is no longer present but the patient is continuing on anticoagulants, the diagnosis changes to “History of DVT” and stays on the problem list because of the importance of anticoagulation management. The same is true for gastrointestinal (GI) bleeding. Once resolved, the problem becomes “History of GI bleed” and remains on the problem list because of its implications for medication selection. If a patient is on a medication for a specific condition, that condition should remain on the problem list as well, but giving it a “History of” designation helps quickly differentiate it from active problems. This is different than “resolving” a problem, which removes it from the problem list entirely.