Problem list
A problem list is a running list of a patient's active and past diagnoses and issues, kept current so any clinician sees the whole picture at a glance.
Why it matters in a workup
A good problem list separates active problems from resolved ones and gives dates. It is often the first thing a new clinician reads.
An out-of-date list misleads. Check diagnoses inherited from old letters before you carry them forward.
Put it into practice
- Separate active from resolved problems
- Date each entry
- Check inherited diagnoses before carrying them forward
Frequently asked questions
Who keeps the problem list up to date?
Every clinician who changes it. In practice the primary care physician often maintains the longitudinal list and hospital teams update it at discharge.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- Medication reconciliationMedication reconciliation compares every list of a patient's medicines to produce one accurate list of what they actually take, with doses.
- Discharge summaryA discharge summary tells the patient's primary care physician what happened in the hospital: diagnoses, treatment, medication changes and what needs follow-up.