Question

Mrs. Rainwater has been diagnosed with hypertension. This is documented in which section of the patient record

Answer 1

Mrs. Rainwater has been diagnosed with hypertension. This is documented in Problem list and assessment field of the progress note.

• An itemized list of a patient's health issues, such as nontransitive illnesses or diseases, wounds they have sustained, and other issues that have harmed them or are still bothering them, is known as a problem list.
• By highlighting the most significant health aspects of each patient, the problem list enables clinicians to deliver individualized therapy.
• The issue list aids in locating people affected by particular diseases. It is simpler to review medical histories in the electronic health records (EHR) system or analyze medical information and identify all individuals who share a common condition using ICD-11 coded disorders.
• Using the problem list, the care team can carry out quality-improvement initiatives by identifying patient populations with certain diseases, offering follow-up care, and making sure all patients receive treatment that complies with their needs.

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