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Writing a patient's History of Present Illness (HPI) involves detailing the patient's current health issues, including symptoms and their duration. Start by noting the chief complaint, then expand on related factors like timing, severity, and any treatments attempted. This narrative helps healthcare providers understand the patient's condition better. Utilizing a structured Patient Problem List Form can enhance clarity and organization in documenting the HPI.

To create a comprehensive problem list for a patient, start by gathering all pertinent medical information. Include current diagnoses along with any relevant historical conditions. It is essential to document both acute and chronic issues clearly. Using a Patient Problem List Form can help streamline this process and ensure all necessary details are captured efficiently.

Problem lists used within health records are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution. They are an important communication vehicle used throughout the entire healthcare continuum.

EHRs are a vital part of health IT and can: Contain a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results.

Each record in the Problem List can include an ICD-10 code, ICD-10 code description, a personalized title, the onset date of the issue/condition, the status of the issue/condition and additional notes.

Clinical staff members typically expect to find the most important information in the EHR's problem list, which includes a patient's current medical conditions, relevant past medical history as well as any non-clinical factors impacting overall health.

A problem list is a document that states the most important health problems facing a patient such as nontransitive illnesses or diseases, injuries suffered by the patient, and anything else that has affected the patient or is currently ongoing with the patient.

It is good practice for a comprehensive patient problem list to start with the most acute, recent problems, and move towards the least acute, least recent.

ACTIVE PROBLEM LIST: A list of all health issues that affect the individual's current functioning and all health issues potentially requiring monitoring. Active problems include chronic problems such as scoliosis, as well as acute problems.