Problem List Medical Write Up

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Problem List Guidance in the EHR - AHIMA

https://library.ahima.org/doc?oid=104997

Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution. 1 They are an important communication vehicle used throughout the entire healthcare continuum. See more

Sample Write-up in Clerkship - Upstate Medical University

https://www.upstate.edu/medicine/education/clerkship/objectives/sample-writeup.php

Problem list. Decompensated diastolic congestive heart failure; Cirrhosis; Altered mental status; Ascites; Impaired fasting glucose; Bronchocontriction; Eosinophila; …

Problem Lists in Health Records - AHIMA

https://bok.ahima.org/PdfView?oid=106339

The problem list must be a dynamic section of the health record, used primarily for theprovision of care. Examples of problems include health, psychiatric, nursing, dental, …

Problem List Guidance in the EHR. Appendix A: Sample …

https://library.ahima.org/doc?oid=104978

Problem list: a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and …

B. Guide to the Comprehensive Adult H&P Write Up

https://med.ucf.edu/media/2018/08/Guide-to-the-Comprehensive-Adult-H-and-P-Write-up-2017-18.pdf

Heart: PMI nondisplaced and normal size; No thrills or heaves; RRR, S1S2 with no s3 or s4, no murmurs, rubs or gallops Lungs: No increase work of breathing, lungs clear to …

The Problem with Problem Lists—and How EHR …

https://www.chiefhealthcareexecutive.com/view/the-problem-with-problem-lists-and-how-ehr-functionality-can-help-fix-them

Lawrence Weed, MD, pioneered the concept of the problem list in the 1960s. Weed developed what he called the problem-oriented medical record, which consisted of …

Problem List - PCC Learn

https://learn.pcc.com/help/problem-list/

Review a Problem List. Each problem includes a diagnosis description (from SNOMED-CT, or ICD-9 for pre-2014 Problems) and a Resolved/Active/Inactive status. There are also optional fields for …

Sample Written History and Physical Examination

https://www.med.unc.edu/medclerk/wp-content/uploads/sites/877/2018/10/UMNwriteup.pdf

No complaints of dysphagia, nausea, vomiting, or change in stool pattern, consistency, or color. She complains of List positive and negative findings in brief, concise epigastric …

What is a problem list in healthcare? - SearchHealthIT

https://www.techtarget.com/searchhealthit/definition/problem-list

The problem list can also serve as the basis for determining standard measures or report cards for practitioners and care providers. The problem list helps identify patients for …

Take the Problem Out of Problem Lists - AAPC …

https://www.aapc.com/blog/46377-take-the-problem-out-of-problem-lists/

Why Problem Lists Matter Ideally, problem lists should help providers identify the most important health factors for each patient. This allows for customized care for the …

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