Ever find an acute problem such as a fracture, which shows in a Problem List, but healed months ago? Or perhaps the problem list states a case of bronchitis that may have been transient or may actually be Chronic Obstructive Pulmonary Disease (COPD)? After all, a diagnosis of COPD is a collaboration of symptoms and test results. How many clinicians find the spare time to go retrospectively back in the EHR and calculate a patient’s, “coughing with excessive sputum nearly everyday for at least 3 months of the year, for 2 years in a row” ?
But fixing the problem list can be time-consuming and complicated. Isn’t there an alternative (better) way?
Many organizations believe that in order to derive an accurate picture of their population’s health, medication lists can be just as good as their problem list. What if you find a patient taking an atypical antipsychotic medication and they don’t have a diagnosis that coincides on their Problem List? Can we just assume a mental health diagnosis? After all, this conclusion seems logical. Or is it? Is it an oversight on their Problem List or are they prescribed it for an off-label reason? According to the Agency for Healthcare Research and Quality (AHRQ), a 2011 report stated off-label atypical antipsychotic medications uses. This included areas such as; anxiety, ADHD, behavioral disturbances of dementia and severe geriatric agitation, MDD, eating disorders, insomnia, OCD, PTSD, personality disorders, substance abuse, and Tourette's syndrome. .
Therefore, can we really make assumptions?