CERNER MILLENNIUM Diagnoses and Problems In this demonstration we’ll review the distinction between diagnoses and problems, and how to record both. This has been prepared for Millennium code level 2015.01.21 & mPage 6.4. Subsequent updates may display cosmetic & functional changes. Use the keyboard or mouse to advance. Any patient names displayed are fictitious.

Diagnoses vs Problems Diagnosis: AKA Billing Diagnosis—What you’re seeing the patient for today. Your charges are based upon this. These are ICD 10 codes. Problem: AKA Chronic Problems or Problem List—Problems that need to be recorded as part of the medical history, even though you may not be addressing them today. These are SNOMED codes.

There are two places you can record diagnoses & problems There are two places you can record diagnoses & problems. One is on the Table of Contents. The other is on the workflow tabs, or mPages. We’ll start with the Table of Contents.

Billing Diagnoses are at the top. The Problem List is at the bottom. Unfortunately, Cerner misuses the term “Problem” in parentheses on the diagnosis list at the top. Please disregard the word “problem” on the top list.

To add a billing diagnosis, click in the search box & start to type To add a billing diagnosis, click in the search box & start to type. Select your desired match as it appears. If you know it, you can also search for the ICD 10 code. This “IMO Search Box” is by far the easiest way to perform your search.

An older search method is to use the +Add button An older search method is to use the +Add button. It is a more tedious & time-consuming approach, presented here mainly for completeness’ sake. To begin, click +Add.

Type at least part of your diagnosis, then click the search binoculars.

Select your desired diagnosis. Note that you have options here to search by “contains” vs “starts with” vs “exact match” or by ICD 10 code. This is where it can become tedious, because you may have to experiment with these options to find your diagnosis, or to avoid generating a very long results list. You may also have to try several search terms.

Add details as desired. When done click OK Add details as desired. When done click OK. (You could also click OK & Add New to add this diagnosis, then search for another diagnosis.)

The billing diagnosis is added. You can use the Modify button to update the details on the diagnosis; this is also available via right-clicking on the diagnosis.

You use the same approach to search for problems, either through the search box here, or via the +Add button. Again, using the “IMO Search Box” shown here is the far preferable option.

If there are no chronic problems, you should select the No Chronic Problems button.

You can update details or resolve a problem You can update details or resolve a problem. Select a problem, then click Modify.

You can add comments, specify age or date of onset, & add other details. In this example, we’ll change the Status to Resolved.

When done click OK.

You can set the Problems Display to only display Active problems, & the resolved problem won’t appear.

You can convert a diagnosis into a problem You can convert a diagnosis into a problem. For example, if you first diagnose hypertension today, you could click Convert to add it to the Problem List as well.

It works the other way around as well It works the other way around as well. If hypertension were on the Problem List & you were addressing it today, you could click Convert to add it to today’s Billing Diagnoses.

Now let’s look at the Problem List as displayed on workflow mPages, which uses some different terminology. You have a search box, which has a dropdown list in front of it. Here, This Visit means Billing Diagnosis (ICD 10), while Chronic means Problem List. And you can set your selection to both the Billing Diagnoses & Problem List at the same time by picking This Visit and Chronic.

Begin to type your search, then click on your choice.

Your choice is added. Also notice there are two buttons here: This Visit & Chronic. In this case the Chronic button is selected, since we searched for Add new as Chronic.

Similar to the Convert button we saw before, you can also click the This Visit button to add this to the Billing Diagnoses for today. You can also Resolve a chronic problem from here.

If you don’t find your desired search result searching this way, you can click the Problem List heading to take you to the full Table of Contents search previously demonstrated.

It doesn’t matter which method you choose It doesn’t matter which method you choose. Just remember: Billing Diagnosis = This Visit = Diagnosis = ICD 10 Problem List = Problems = Chronic

You or your staff may enter Problem List items as you’re taking the patient’s medical history. You may well come back & add Billing Diagnoses after you’ve evaluated the patient. Make sure to populate both lists before generating your visit note, so they will be included in your note.

Lagniappe Following are a few other tips about the Problem List.

What belongs on the Problem List? There is a little philosophy & personal preference involved here, & Cerner provides you the latitude to decide how you wish to use the Problem List. Probably the most common interpretation is that the Problem List is for active, chronic problems—things that you expect to be enduring, if not lifetime, issues for the patient. Anything you address at a visit that is not a chronic problem is just recorded as a billing diagnosis for that visit.

An alternate interpretation would be to include even temporarily “problems” on the Problem List—things that you expect to have to address for several visits, but to eventually resolve. Following that interpretation, one might, for example, put Pregnancy on the Problem List (in addition to using Pregnancy as a billing diagnosis). If you take that approach, however, you need to remember to use Modify to resolve the problem once it is over with.

Change Status to Resolved Change Status to Resolved. You can also update other details & add Comments as desired.

There are a number of details on the Problem List There are a number of details on the Problem List. Though many may not be per pertinent on any given problem, it is helpful to be familiar with the available details. Many details will display on the columns to the right, though you may have to scroll to see them. And to see the full list of details, select a problem & then click Modify.

Feel free use the many available details and the Comments field to fully “tell the story.”

One detail you’ll sometimes need to notice is Classification One detail you’ll sometimes need to notice is Classification. When you manually add an item to the Problem List, the Classification will be Medical. And you usually don’t even have to think about that.

But there are other options on the list that sometimes come into play.

On patients who have been hospitalized, you may see items on the Problem List with the Classification of Interdisciplinary or Nursing. These are often not things you would think of putting on the typical “medical record” Problem List. Some may be very wordy or not readily clear. They’re problems that are added during the hospitalization through nursing documentation or quality-based rules. In the days of paper medical records, these would be recorded elsewhere, but in Unity they’re added to the Problem List, distinguished by the Classification.

You may also see problems with the Classification of Patient Stated You may also see problems with the Classification of Patient Stated. Though it is possible use of this Classification will be expanded in future updates, the most common example seen today is Tobacco Use, which is automatically added when this fact is recorded via the Social History.

An important thing to understand is that only problems with the Classification of Medical appear in encounter notes. So you don’t have to worry about the other Classifications ending up in your notes. But what if, for example, you wanted Tobacco Use to appear in your visit note? Select it & click Modify.

Then change Classification to Medical Then change Classification to Medical. It will now appear in your encounter documentation.

You can filter what you see on the Problem List. Sometimes the Problem List can grow very long, to the point it appears cluttered & requires scrolling to view everything. This may especially happen on patients who have had multiple, involved hospitalizations. So you might want to filter the display to see the things that you’re most interested in.

You can click the Display dropdown to see a list of options You can click the Display dropdown to see a list of options. This list will probably initially be short, & may not give you all the options you’d like. You can add other filtering options by clicking the Ellipsis Button.

In particular, notice that you can filter by both Status & Classification. To create a new display filter, click New.

In this example, we’ll create a new filter that shows only Active problems, with Classification of Medical or Patient Stated. We’ll type that name at the top, then select only the Active checkbox.

Select Available Classifications & use the Add or Remove buttons to place Medical & Patient Stated on the Available Classifications list. You can set this as your Default display filter if you like. When done, click Save.

Now only Active Medical & Patient Stated problems display on the list Now only Active Medical & Patient Stated problems display on the list. So you see what will appear in your note, & what Patient Stated problems you might want to change to the Classification of Medical to make them appear in your note as well.

Your newly-created filter will also now appear on the Display dropdown list for rapid use.

It’s easy to be overwhelmed by all these details, so remember you usually don’t need to think about most of them. Just be aware of when they can be used to your advantage, or to add information you would otherwise have no way to record.