Template  BC CDA E2E Problem List with Entries

The problem list may be viewed as the table of contents into the patient’s record. While some of the information that would be exchanged in a CDA type document would be of transient interest items in the Problem List would be of more enduring interest. Information in the problem list may be used for various functions including providing a summary of issues, concerns or conditions that the patient has or had. The other functions would be to provide the indication or reasons that various other activities were done. When a medication is prescribed the prescription could be linked to one or more problems as could investigations and referrals. For an individual encounter one or more Problems could be selected as having been an issue during that encounter.

The BC College of Physicians and Surgeons stipulates that a patient`s medical record include a problem list. This is difficult to maintain in a paper chart. Time and effort needs to go into maintaining a computer based Problem List but the increased utility can be the benefit. The Problem List can be used as the basis of a chronic disease registry and for identifying patients that could be billed for various GPSC chronic disease management fees. The utility of the Problem List can be seen in routine encounters when referrals are being made or investigations are ordered.