Patient Encounter: Problem List

Version 14.8

About Patient Encounter: Problem List Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Problem List tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Problem List tab

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Problem list tab displays and documents all patient Diagnoses and Problems for the patient’s past medical history, allows for Tracking specific Diagnoses or Problems for reporting purposes, shows scanned items, and adds/edits chart note worksheets.

Patient Encounter: Problem List Tab Map



Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:


Care Plans tab
The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
Visit Date
The Visit date field indicates the date that the patient encounter occured.
Prior Notes tab
The Prior Notes tab lists the previous encounter notes and messages.


Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.

Function buttons
The Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
Flag as Incomplete checkbox
The Flag as Incomplete checkbox will mark an encounter as unfinished.
PMFS History/Meds Reviewed
The PMFS History/Meds Reviewed field is a text box where you can enter or review a patients past or current problems.  You can also indicate that the patient does not have any problems in this field.  Current medical problems can also be listed in this field.
List tabs
Tabs in the Patient Encounter: Problem List are:
  • Problem List: The Problem List tab contains a complete list of problems for a patient's present and past medical history.
  • Scanned Records:  The Scanned records tab displays a patient's scanned item with the label "Chart" as the item type in its document properties.  This tab sorts images by date, category staff, etc.  It also can change the recipient directly from the scan window.  This tab does not include items link directly to notes on the Problem List tab.
  • Worksheets: Contains worksheets that had been previously entered into OP 14. The grid can display the worksheet questions, question descriptions, and chart notes in the grid.
Problem List Function buttons
The Problem List functions buttons:
  • Print: Prints the patient Problem List.
  • Add: Opens the Problem List window to add a problem to the Problem List.
  • Edit:  The Edit button opens the Problem list window to alter the selected problem in the problem list.
  • Delete: The Delete button deletes a problem from the problem list.
  • Move:  The Move buttons move a problem up and down in the problem list.
  • Reviewed:  The Reviewed button marks a selected problem in the problem list as reviewed.  The reviewed indication is time stamped.
  • No Problems button:  The No Problems button  provides an indicator that there are no active problems for the patient.
Problems List

The Problems List is a list of all the patient's medical conditions (past and present).  The list indicates the problem, status, onset date, resolved indication, updated, and privacy level. Clicking on the Paperclip button will add the selected problem to the PMFS History text box as well as add a sentence that the Problem List was reviewed with a date and time stamp.