Problem list is an important part of the patient’s electronic medical record

Problem list is an important part of the patient’s electronic medical record (EMR) since it is the summary of key elements of the patient’s health history, information from parts of the medical records and is used as an easy access and reference by the healthcare team (Sullivan, 2011). Furthermore, the problem list opens up automatically when the record opens up within the patient’s chart. The problem list can be in active or inactive format where the active problems include current or chronic conditions that require ongoing management. On the other hand, the inactive problems include the health problems in the past that are now resolved, and these problems can be either medical or surgical. Moreover, the problem list for each facility or organization may differ based on their needs (Sullivan, 2011). On the other hand, the medication list provides an easy and quick format to document the patient’s medication at a given time. The medication list is detailed medication therapy that the patient is currently taking including over-the-counter medications, herbal medications, dietary supplements, and vitamins. In addition, the medication list can alert any contraindications with another medication or disease (Sullivan, 2016). Moreover, the medication list also includes the pharmacy information including the name, phone and tax number, and location of the pharmacy for electronic prescription. In primary care settings, physicals or the nurses have the opportunity to update the patient’s problem list as well as the medication list to be up to date. Some patients may visit the primary care providers after a hospital stay and they may have a new medication list and problems, which needs to be addressed, and updates on the patient’s problem and medication list within the electronic medical record system.

In order to maintain these two important lists, a nurse or the medical assistant should update the information when they are checking the patient’s vital signs, which is one of the first tasks during a patient’s appointment. According to Rolls (2016), the social media can have both negative and positive impact on the nurses. However, if social media is being used professionally as developing virtual communities to share domain knowledge while being aware and extra cautious of HIPAA.

References

Rolls, K., Hansen, M., Jackson, D., & Elliott, D. (2016). How Health Care Professionals Use Social Media to Create Virtual Communities: An Integrative Review. Journal of medical Internet research, 18(6), e166. https://doi.org/10.2196/jmir.5312

Sullivan, D. D. Guide to Clinical Documentation. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9780803694194/