1.  Using the Problem List to Improve Documentation Dave Mooradian, M.D. CMIO

2. Using the Problem List - Admission When entering a new hospital problem, the problem list calculator will assist in meeting documentation specificity requirements for ICD-10 and Present on Admission. Use the “Overview Note” section in order to include problem specific plans within the Admission H&P template when entering a new hospital problem or addressing an existing hospital problem. 2

3. Using the Problem List - Admission Select appropriate modifiers to make diagnoses more specific for ICD-10 3

4. Using the Problem List - Admission Document Present on Admission status and Overview note to summarize plan 4

5. Using the Problem List - Admission Click Create/Edit Overview to enter Overview note on an existing problem 5

6. Using the Problem List - Admission Click H&P Notes from within the Admission Navigator The problem list with overview notes are automatically included 6

7. Using the Problem List - Admission If Present on Admission is not addressed on the Problem List (PL), a Best Practice Advisory (BPA) will display that will redirect you to the PL for completion 7

8. Using the Problem List – Problem Oriented Charting Used to document daily Progress Note Accessed via the Problem Oriented Charting Navigator 8

9. Using the Problem List – Problem Oriented Charting First section – Select Hospital Service will default for those with only one specialty defined. MUST be completed in order to use Problem Oriented Charting 9

10. Using the Problem List – Problem Oriented Charting Subjective/Objective section Upon opening smarttext appears Complete required *** Each specialty’s note will be independent of each other 10

11. Using the Problem List – Problem Oriented Charting Problem List section Allows problem specific assessment and plan notes Click Create Assessment & Plan Note and document for each problem you are addressing 11

12. Using the Problem List – Problem Oriented Charting Enter text Click Next (or use Voice Command for Next) to move to the next Problem’s Create Assessment & Plan Note 12

13. Using the Problem List – Problem Oriented Charting When all desired assessment and plan notes are complete, click Generate Note 13

14. Using the Problem List – Problem Oriented Charting Note is generated in APSO format 14

15. Using the Problem List – Problem Oriented Charting There are 2 options for completing the Physical Exam, using a “dot phrase” or using Notewriter. To complete via “dot phrase”, within the note under Physical Exam type “.pexmale” or “.pexfemale” or a physical exam of your choice. Complete smartlists and remainder of progress note and Sign. 15

16. Using the Problem List – Problem Oriented Charting To complete Exam in Notewriter, Click Pend. Click “Edit in Notewriter” in Progress Notes section of navigator Notewriter opens with Physical Exam Smartform. Complete the physical exam, remainder of progress note and Sign. 16

17. Using the Problem List – Problem Oriented Charting 17

18. Using the Problem List – Problem Oriented Charting 18

19. Using the Problem List - Discharge Via the Discharge Navigator, indicate problems that are resolved 19

20. Using the Problem List - Discharge Click Discharge Summary on the Discharge Navigator A list of all hospital problems during the encounter, both active and resolved are listed with the present on admission status Complete remaining elements of template using Voice to Text. 20