Let’s Fix the Problem List Today . . . Hello, Nurses!

Craig Joseph, MD
By: Craig Joseph, MD
Date: June 06, 2019

The electronic health record (EHR) problem list is . . . well, it’s a problem. I’ve worked with many of the leading EHR vendors and their tools, and no one has solved this quandary. While I haven’t met a physician (or any clinician for that matter) who doesn’t want a well-maintained and curated longitudinal problem list for their patients, I have met many doctors who don’t want to take on the responsibility. “I’m just the specialist” or “I’m in the ED” are common statements, but one might argue (I might argue) that these are the very folks who benefit the most from an up-to-date list of patient issues and concerns.

There are technical and software development options that users have requested for a long time which might improve the usability and usefulness of the EHR problem list. Some of these include:

  • Personalized views so we don’t have to argue about the differences between past medical history (PMH) and problem list.
  • Clinically-meaningful categorization of problems that is dynamic and responsive to the patient, the clinician, the setting, and the history.
  • Some minimal and obvious automatization of problem list maintenance (e.g. if sepsis is still on the problem list six months after the patient’s discharge from the hospital, maybe it should be listed as resolved.)

EHR problem list

But since these technical assists aren’t coming fast enough, I wish there were some solution in play today. If only there were others on the care team who could help. If only . . . <cue dream sequence>

I keep hearing that medicine needs to be a team sport. Well, let’s get to it. Nurses should most certainly be allowed to contribute to and maintain the problem list. What could possibly go wrong if we allow nurses a seat at the patient’s problem list table? Let’s list the issues out, and then see how we can mitigate them.

Nurses aren’t licensed or trained to practice medicine. And we all know that diagnosing a patient is part and parcel of practicing medicine. So how can we expect nurses to help manage the problem list? Simple! They’re smart; they can read; they can hear! When the doctor writes in her note that the patient’s COPD exacerbation is slowly resolving, I think we can all agree it’s likely the physician has diagnosed the patient with COPD. Let’s put that bad boy on the problem list.

Nurses are very detail oriented. And I mentioned before that they can read! What might an experienced nurse do with the following data?

  • January – ED physician adds “headache” to the problem list
  • March – Primary care doc adds “migraine” to the problem list
  • June – Neurologist adds “migraine with aura” to the problem list

I would posit that a nurse might just delete/remove/resolve the first two less-specific diagnoses, since it seems clear that the most definitive and most recent diagnosis made by the appropriate specialist is the most accurate one.

Am I taking responsibility away from the physicians so that now the problem list belongs to the nurses? No. Should it be their job alone to keep the problem list up-to-date? No. I’m not relieving physicians of their work. They alone diagnose patients. But I am proposing that nurses can play a part in this important duty. When I’m asked who should be responsible for maintaining the problem list, I always reply, “Yes!” That’s my cute way of saying that anyone who has the requisite skill and experience should contribute to the problem list.

Should every nurse contribute to the problem list? Not on your life. Nurses that are just out of school will likely find it difficult to “read” the note or the doctor. The only thing worse than serious problems not being on the problem list is . . . not serious problems being on the problem list. I think experienced nurses know what they know. If there is a question about what to do, then do nothing.

I have no doubt that some folks from Compliance or Legal or Risk are having chest pain right now just thinking about nurses contributing to the problem list. But when we really analyze the advantages versus the disadvantages, I think the risk of a poor outcome is small compared to the benefits of an up-to-date problem list. And for the record, if the chest pain is short-lived and resolves with thoughtful conversation about the nurse’s role in modern medicine, I would not put chest pain on the problem list!

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