A problem list in a medical record is a structured, longitudinal summary of a patient’s most significant health conditions and issues. This list is a core component of the Electronic Health Record (EHR) and provides a quick overview of a patient’s medical history for any authorized healthcare provider. It serves as an index to the entire medical chart, helping clinicians rapidly grasp the patient’s context without having to read through every progress note or test result. It is an evolving record that reflects the patient’s changing health status over time.
What Information is Included
The information populating a comprehensive problem list extends beyond simple disease diagnoses to include any factor impacting a patient’s overall well-being. At the foundation are the active problems, which are current diagnoses or conditions requiring ongoing management, such as Type 2 Diabetes or Chronic Kidney Disease. These entries represent the health issues a provider must consider during a present-day appointment.
The list also maintains a history of inactive or resolved problems, which are conditions that have been treated, cured, or are no longer acutely relevant. For example, a previous episode of cancer in remission or a past surgical procedure would be maintained to inform future decision-making. The inclusion of these historical items provides context for comprehensive care.
Beyond traditional medical diagnoses, a modern problem list incorporates other factors influencing health, including social and environmental issues. These may involve entries noting housing instability, lack of access to transportation, or behavioral health concerns, which are recognized as significant determinants of health outcomes. The list also tracks relevant risk factors, such as a strong family history of coronary artery disease or documented tobacco use, to alert providers to potential future health concerns.
For consistency and to facilitate data exchange, each entry is often associated with a standardized clinical terminology. In the United States, this typically involves the use of Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) for clinical description and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for administrative and billing purposes. SNOMED CT offers the granular detail needed for documentation, while ICD-10-CM codes ensure a common language for reporting and reimbursement.
The Role in Treatment and Care Coordination
The primary function of the problem list is to ensure seamless continuity of care across the entire healthcare spectrum. Any clinician—whether a primary care physician, a specialist, or an emergency department doctor—can quickly review this summary to understand the patient’s full medical context. This rapid access to history is especially valuable when a patient is seeing a new provider or receiving urgent care.
The list acts as a decision support tool, directly enhancing patient safety and guiding treatment choices. For instance, if a patient has a condition like chronic heart failure listed, the EHR system can flag a potential drug interaction or suggest a treatment modification when a new medication is prescribed. This preemptive alerting helps providers avoid prescribing medications that are contraindicated by a listed condition, minimizing the risk of adverse events.
It also promotes standardized communication among the multidisciplinary care team. By requiring all providers to use the same terminology for a patient’s conditions, the problem list ensures that everyone involved in the patient’s care has a shared, accurate understanding of their current status and treatment goals. This shared understanding is necessary for coordinating complex care plans, particularly for patients managing multiple chronic diseases.
Furthermore, the problem list is instrumental in population health management and quality reporting initiatives. Healthcare organizations use the structured data from these lists to identify groups of patients with specific conditions, such as diabetes or asthma, to ensure they receive timely preventative screenings and follow-up care. This use helps healthcare systems measure their performance and ensure that care meets established quality standards.
Ensuring Accuracy and Updating the List
A problem list must be a dynamic, living document to maintain its utility, evolving as the patient’s health status changes over time. Its value depends entirely on its accuracy, as an outdated or cluttered list can obscure important information and undermine clinical decision-making.
The responsibility for curating this record falls primarily to the clinician, such as the physician or nurse practitioner, who should review and reconcile the list at every patient encounter. During this review, symptoms that have evolved into a definitive diagnosis should be updated, and any duplicate entries should be removed to keep the list concise. Clinicians must also clearly designate problems as either “active” or “resolved” to reflect the current status of the condition.
The proper dating and chronology of entries are also important, indicating when a problem began and, if applicable, when it was resolved or moved to an inactive status. For conditions that are no longer active but still influence future care—such as a past blood clot requiring long-term blood thinners—the entry is often kept on the list with a “history of” designation.
Patients are increasingly playing a role in maintaining the list’s accuracy, often through secure patient portals that allow them to review their health information. By giving patients the ability to see the list, providers can be alerted to potential errors or omissions. This collective effort between the patient and the care team ensures the problem list serves its intended function.