# Adding a Problem

The Problems tab now uses Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) for documenting problems on the patient’s problem list.

Note: Remember that the diagnosis on the Encounter form can be added to the Problems tab by simply selecting the checkbox to put it there.

With the Lexicon search, the initial search contains frequently used problems within the VA and new problems are added each Lexicon Quarterly release. The Extended Search represents a larger subset of SNOMED CT containing all the terms from the Clinical Findings, Events, and Situation with Explicit Context hierarchies. Currently, all terms are linked to a placeholder ICD-10-CM code of R69 and may be updated through the Encounter Form workflow.

To speed up documentation in Problem List and to avoid the dual entry in the Encounter Form application, enhancements were completed to enable the use of the VA-National Problem Selection List or a VISN, or local problem selection list. Sites can use the National Problem Selection List that has curated Problem Categories with problems represented in SNOMED CT that are linked to ICD-10-CM code(s). In addition, sites can create Local Problem Selection Lists. Users or clinics who want to create their own Local Problem Selection List will need to request this from a Clinical Application Coordinator (CAC) and will be responsible for maintaining these Local lists.

It is highly recommended that sites use the National Problem Selection List because it will be nationally maintained. The National Problem Selection List will display by default unless the user or clinic already has a Problem Selection List defined. The Problem Selection List is displayed in the left pane of the Add a New Problem dialog.

To add a new problem to a patient’s problem list, use these steps:

1. Select the Problems tab.

2. Select New Problem

-or-

select Action | New Problem... .

The Problem List Lexicon Search dialog displays.

Note: If encounter information has not been entered, the encounter information dialog will appear before the Problem List Lexicon Search dialog. You must enter an encounter location and provider before proceeding.

If sites have not assigned a different problem selection list to a user or clinic, the VA-National Problem List Selection list will display as shown above. The top pane shows the problem categories. Selecting a category will display the problems in that category in the pane below.

3. If the user is set up to use the National Problem Selection List the National Problem Categories with the associated problem are displayed based on the category. If the problem is not found within the category, skip to step 4 by selecting Other Problem to bring up the Problem List Lexicon Search dialog.

The Problem List Lexicon Search dialog enables users to search for the term that best describes the patient’s problem. SNOMED codes are used to define the problems..

4. Enter part or all of a term that describes the problem in the Enter Term to Search field and press <Enter> or select Search .

CPRS will search the lexicon for problems that contain the search term. The matching problems will appear in the bottom portion of the Problem List Lexicon Search dialog. The search now looks for SNOMED Clinical Terms (SNOMED CT). There is also a parameter to hide the codes if sites so choose.

In this search, some items have additional items grouped under them. The user can expand items with an arrow next to them to see additional items.

5. Select the appropriate term if it is in the list. If you do not see the appropriate problem listed, select the Extend Search button.

On the Problems tab, the Extend Search button extends the search to a larger subset of SNOMED CT.

When the search is extended by the user, more matching results are returned that are linked to the ICD-10-CM R69. If the user still does not find the desired term, the user may choose to enter a free text entry by selecting the Freetext Problem button.

6. If the user does not find the desired term using the Extend Search they may choose to enter a free text entry, the user may choose to do the following actions.

To refine your search, select No and return to step 4. To use this term, select Yes and go to step 7.

o Terms Found But Not Adequate: If the extended search displays terms, but not the one you want, you will need to decide whether to enter a free-text term or revise your search.

To begin the search again using another term, return to step 4 and use another term to identify the problem.

To enter a free-text term, select the Freetext Term button. The Unresolved Entry dialog will display as shown below:

This dialog shows when the system does not find any terms that match the text entered by the provider or when the provider selects the Freetext button because an adequate term is not displayed. From the Unresolved Entry dialog, the provi der can choose to use the term as entered, and if needed, request that it be added as a new term.

To use this term, you first need to decide if you want to request that the term you entered be added as a new term. To request a new term, you need to check the Request New Term check box and add a comment if needed. If not, leave the check box unchecked. Then, to add this term to the Problem List as entered, select Yes and go to step 8.

Note: If you request a new term, a bulletin is sent to a local group for review. This group will then forward the request if it concurs that a new term is needed.

o No Terms Found: If the extended search finds no terms, the Unresolved Entry dialog will display as shown below. To try another search, select No and return to step 4.

Note: If you try to select a problem that has an inactive diagnosis or procedure code, you will be prompted to select a problem with an active code. If you select a term that is not mapped to a specific ICD-9-CM code (one with a 799.9 designation--Other unknown and unspecified cause of morbidity or mortality), a dialog will warn the user that the term is not mapped, tell the user that the term will be reviewed and will not be available for selection on the Encounter form, and then ask if the user wants to use that term or cancel their selection. If the user chooses to use the term, a bulletin will be sent to the Standards and Terminology Services team to consider mapping the term to a specific term.

The New Problem form will appear.

The New Problem form

7. Complete the New Problem form by following the steps below:

a) Select a status for the problem (Active or Inactive).

b) Choose an immediacy for the problem (Active , Chronic, or unknown ).

c) Enter the date of onset.

d) Select a respo nsible provider from the drop-down list .

e) Choose clinic from the drop-down list.

f) Enter any comments (if necessary) by pressing the Add comment button. You can also edit a comment or remove the comment usin g the appropriate buttons.

8. Select OK .

Related Topics

Problems List

Annotating a Problem

Changing a Problem

Customizing the Problems List

Making a Problem Inactive

Removing a Problem

Verifying a Problem