1. Problem List Definitions & Conventions

2. Major Functions Table of Contents for the Health Record Table of Contents for the Health Record Information Bulletin Board for Communication Among Providers Information Bulletin Board for Communication Among Providers Synopsis of Medically Significant Events Synopsis of Medically Significant Events

3. Active Problems Include important medical, social, and psychiatric problems Include important medical, social, and psychiatric problems Have clinical significance and currently affect the patient (Diabetes) Have clinical significance and currently affect the patient (Diabetes) May be presently quiescent but are still at high risk to recur (CHF) May be presently quiescent but are still at high risk to recur (CHF) May be temporarily active (Pregnancy, Burns) May be temporarily active (Pregnancy, Burns)

4. Inactive Problems Have a tendency to recur Have a tendency to recur Place the patient at risk Place the patient at risk Include resolved conditions Include resolved conditions Include positive skin test, OB, or birth information Include positive skin test, OB, or birth information

5. Surgery Although surgical conditions that place a patient at risk are usually included in a problem list, they should not be added to the Problem List because they are displayed on the health summary in the History of Surgery section. Use mnemonic SHX to enter a surgery Although surgical conditions that place a patient at risk are usually included in a problem list, they should not be added to the Problem List because they are displayed on the health summary in the History of Surgery section. Use mnemonic SHX to enter a surgery

6. Problems That Are Always Considered Active Abuse Abuse Alcohol Related Injuries Alcohol Related Injuries Allergies Allergies Amputations Amputations Blindness Blindness Deafness Deafness Diabetes Diabetes Epilepsy Epilepsy Hypertension Hypertension Paralysis Paralysis Recurrent Otitis Media Recurrent Otitis Media Rheumatoid Arthritis Rheumatoid Arthritis Suicide Attempts Suicide Attempts Violence Related Injuries Violence Related Injuries Recurrent Urinary Tract Infection Recurrent Urinary Tract Infection

7. Where to Look for Active Problems Last five encounters or past six months Last five encounters or past six months Inactive Problem List Inactive Problem List Hospital discharge reports Hospital discharge reports Consultants reports Consultants reports