(From the September 2015 Issue of MedStat)
A quick check of 10 medical records of patients discharged from Nationwide Children’s Hospital in the previous 24 hours revealed that only 7 of 10 records had an updated Problem List that reflected the recent hospitalization. For example, a neonate was evaluated for vesicoureteral reflux (VUR) and required a VCUG and follow-up with Urology after discharge. The VUR was not listed on the Problem List. That information might be important to a subsequent emergency medicine provider who was evaluating the infant for fever and possible sepsis.
So, how do you decide what goes on the patient’s problem list and what should be on the list? Please review this month’s Medstat insert (PDF). Contact Rick McClead, MD, associate chief medical officer at (614) 722-5121 or Richard.McClead@NationwideChildrens.org.