# Adding a Problem

The Problems tab now uses Systematized Nomenclature of Medicine--Clinical Terms (SNOMED CT) for the initial search instead of ICD-9-CM terms. SNOMED terms are then mapped to ICD-9-CM terms in the background. The SNOMED CT coding system was created by pathologists and should help providers to better describe a patient's problems. This change of coding systems does not affect problems that were previously entered on the Problems tab. You do NOT need to change previous problems to SNOMED terms.

Also, for Encounter data, providers must use a term that is mapped to a valid ICD-9-CM code. For Encounter information, t he initial search also uses SNOMED terms, but will also display ICD-9-CM codes.

Note: Remember that the diagnosis on the Encounter form can be added to the Problems tab by simply selecting the check box to put it there.

As with any change, moving to a new system will take some getting used to. Although the SNOMED CT codes should be robust enough to describe most problems or patient conditions, providers may have to try slightly different ways to search for the problem they want. For example, if providers are accustomed to entering "HTN" to find hypertension, the providers may need to search for "hyper" instead.

However, some SNOMED terms may not be mapped to ICD-9-CM codes. To further aid providers, CPRS has added an Exte nd Search button. If in the initial search CPRS does not display the term the provider wants, the provider can use the Extend Search button to expand the search to a larger set of codes that include the ICD-9-CM clinical hierarchy. CPRS will then display a combination of SNOMED and ICD-9-CM codes including codes that might have 799.9 (unknown or undefined) codes.

With this change, CPRS will keep the SNOMED codes and map the codes in the background when ICD-10 codes come into use in 2013.

To further help providers find the terms they need, CPRS allows site to create "pick lists" that sites can use to create a list of frequently used terms which will be readily available in the left pane of the Add a New Problem dialog. Providers who want "pick lists" create will need to request this from a Clinical Application Coordinator (CAC). Users cannot create the lists themselves. A CAC must create the list and assign it.

During the search, if no matches are found during the initial and extended search, CPRS has a way to request that a new SNOMED term for the problem. The provider is not required to enter a new term, but can so that perhaps a new term will get created or someone may provide feedback for a better term. However, whether the provider requests a new term o r not, if the provider still wants to enter a term, the provider will need to initiate a revised search to find a different term for the problem. It might be a slightly broader term that will still cover the problem. The provider could then enter a comment to be more descriptive about the term.

If the provider wants to use the SNOMED code for encounter information, the SNOMED code must be mapped to an ICD-9-CM code. If it is not currently mapped, the provider will need to find a SNOMED code that is mapped or select an ICD-9-CM code.

To add a new problem to a patient's problem list, use these steps:

1. Select the Problems tab.

2. Select New Problem

-or-

select Action | New Problem....

The Problem List Lexicon Search dialog displays.

Note: If encounter information has not been entered, the encounter information dialog will appear before the Problem List Lexicon Search dialog. You must complete the encounter information dialog before proceeding. Also, if your site has defined Problem List Categories, the display will show them first. If you select a category, skip to step 6.

For sites that have problem pick lists, the Problem List will display with the Problem Categories and then the Problems for each category below.

3. If no pick lists are defined, skip to step 4. If the Problem Pick List displayed with the Problem Categories and Problems defined for each category, select Other Problem to bring up the Problem List Lexicon Search dialog.

The Problem Li st Lexicon Search dialog enables users to search for the term that best describes the patient s problem. SNOMED codes are used to define the problems. ICD codes are also included.

4. Enter part of all of a term that describes the problem in the Enter Term to Search field and press <Enter> or select Search.

CPRS will search the lexicon for problems that contain the search term. The matching problems will appear in the bottom half of the Problem List Lexicon Search dialog. The search now looks for SNOMED Con cepts Terms (SNOMED CT). Most terms will also be mapped to an ICD-9-CM code. The list will show the SNOMED concept text, the SNOMED code, and the ICD-9-CM code if the term is mapped to one. There is also a parameter to hide the codes if sites so choose.

When searching for a term, the Problem List Lexicon Search now finds SNOMED concepts mapped to specific ICD-9-CM codes.

5. Select the appropriate term if it is in the list. If you do not see the appropriate problem listed, select the Extend Search button.

On the Problems tab, the Extend Search button extends the search to the SNOMED clinical hierarchy to find additional terms. These new terms may not be mapped to specific ICD-9-CM codes, but instead mapped to 799.9 codes. Or the term may n ot be found at all.

When the search is extended by the user, a number of codes are shown. Many of these codes are not mapped to specific codes, but are mapped to 799.9, which is undefined. Also, the Freetext Problem button displays.

6. Based on the results of the extended search, you will need to take one of the following actions:

o Terms Found (most common): If the appropriate term displays, select the appropriate term and go to step 7. If the term you select is not mapped to an ICD-9-CM code but has a 799.9 designation, the following dialog will display.

If the user selects a term with a 799.9 code, this dialog displays.

To refine your search, select No and return to step 4. To use this term, select Yes and go to step 7.

o Terms Found But Not Adequate: If the extended search displays terms, but not the one you want, you will need to decide whether to enter a free-text term or revise your search.

To begin the search again using another term, return to step 4 and use another term to identify the problem.

To enter a free-text term, select the Freetext Term button. The Unresolved Entry dialog will display as shown below:

This dialog shows when the system does not find any terms that match the text entered by the provider or when the provider selects the Freetext button because an adequate term is not displayed. From the Unresolved Entry dialog, the provi der can choose to use the term as entered, and if needed, request that it be added as a new term.

To use this term, you first need to decide if you want to request that the term you entered be added as a new term. To request a new term, you need to check t he Request New Term check box and add a comment if needed. If not, leave the check box unchecked. Then, to add this term to the Problem List as entered, select Yes and go to step 10.

Note: If you request a new term, a bulletin is sent to a local group for review. This group will then forward the request if it concurs that a new term is needed.

o No Terms Found: If the extended search finds no terms, the Unresolved Entry dialog will display as shown below. To try another search, select No and return to step 4.

Note: If you try to select a problem that has an inactive diagnosis or procedure code, you will be prompted to select a problem with an active code. If you select a term that is not mapped to a specific ICD-9-CM code (one with a 799.9 designation--Other unknown and unspecified cause of morbidity or mortality), a dialog will warn the user that the term is not mapped, tell the user that the term will be reviewed and will not be available for selection on the Encounter form, and then ask if the user wants to use that term or cancel their selection. If the user chooses to use the term, a bulletin will be sent to the Standards and Terminology Services team to consider mapping the term to a specific term.

The New Problem form will appear.

7. Complete the New Problem form by following the steps below:

a) Select a status for the problem (Active or Inactive).

b) Choose an immediacy for the problem (Active, Chronic, or unknown).

c) Enter the date of onset.

d) Select a respo nsible provider from the drop-down list.

e) Choose clinic from the drop-down list.

f) Check any applicable treatment factors that apply to this problem.

g) Enter any comments (if necessary) by pressing the Add comment button. You can also edit a comment or remove the comment usin g the appropriate buttons.

8. Select OK.

Related Topics

Problems List

Annotating a Problem

Changing a Problem

Customizing the Problems List

Making a Problem Inactive

Removing a Problem

Verifying a Problem