The Importance of an Accurate Problem List

Executive Summary

Problem lists are a key component of good documentation in a physician’s office, as they help practitioners identify the most important and unique health factors for each patient. Problem lists help prevent failures to diagnose or delays in diagnosis that can lead to lawsuits.

Recommended Actions

• Develop problem lists that are specific to the patient and their primary complaints.

• Implement a system to track when patient tests are completed and ready for review.
• Discuss concerns and a possible diagnosis with patients so they are aware of the need for further treatment or follow-up care.

Case Study  

Mr. A was a 58-year-old male who went to see Dr. B in January 2005 for a physical exam. The patient had a history of hypertension and hyperlipdemia controlled on an ACE Inhibitor and a statin. Upon a review of systems, the patient complained of bright red blood per rectum when he had a bowel movement. The physical exam was unremarkable and the patient’s stool guaiac was negative. The notes suggested a gastrointestinal referral for a colonoscopy. There was no separate referral form for a colonoscopy, however, which was required by the patient’s insurance. The patient’s lab tests were unremarkable except for a mild anemia, (HCT of 36).

The patient returned three times (over the next year and a half) for respiratory infections and intercurrent illnesses. The colonoscopy and bleeding were never mentioned in any of these visits. In July 2006, Mr. A presented to the ER with abdominal pain, fever, nausea and vomiting. The patient was admitted and underwent an exploratory laparotomy, which revealed widespread cancer of the colon. He was eventually found to have stage IV cancer and was treated with chemotherapy. The patient died in January 2007 and a lawsuit was filed.

Discussion

There are multiple areas of weakness in defending the care provided by Dr. B.

Assessment

Sometimes there is confusion around the difference between screening and symptomatic evaluations. There are a variety of guidelines and practices around the screening of asymptomatic patients. In this case, the medical assessment was correct. With the patient’s age group, the complaint of bleeding and anemia is best addressed with a colonoscopy. This was correctly suggested as colon pathology would be the biggest concern in this patient.

Follow-Up and Problem Lists

The hardest issue to defend is that there were several follow-up visits where the findings of anemia and bleeding were not discussed. Dr. B’s office did not use problem lists in charts (paper at the time). An up-to-date problem list means providers don’t have to rely on memory to address worrisome issues. In the office, the problem list helps practitioners identify the most important health factors for each patient, allowing for customized care.

Beyond the broad categorical determinants, a point of debate concerns the type of diagnosed illnesses worthy of the problem list. Currently, the decision about problems to include or exclude remains largely the determination of practitioners. While one practitioner may argue that chicken pox is a relevant problem for assessing risk for shingles and the need for a chicken pox vaccination, another practitioner can debate that its inclusion adds little value and clutters the list.

The inclusion of an illness on the problem list likely will vary by patient as well. Exercise-induced asthma will be important information about a patient on several asthma medications, but it may not be important if the patient is not seeking treatment, takes no related medications, and is not affected by the illness in his or her daily life. Long-term undiagnosed symptoms also fall within this difficult category. A patient may complain of a cough for years, but have no clear diagnosis. This should be included on a good problem list. Problem lists are a key component of good documentation in a primary care office.

In addition to the lack of a problem list, there are other system issues apparent in this case study. Why wasn’t a referral generated? The physician was at a loss to explain this. Plus, there was no tickler file. If tests are suggested and are medically necessary, the office should have some system to track their completion.

Communication

Finally, there is an issue around communication with the patient. If the physician had clearly explained the risk and concern he had, then some of the responsibility would have been on the patient. A reasonable patient told that they might have cancer could be expected to demand more workup. The lack of documentation of any such discussion adds to the difficulty in defending Dr. B's care.

Failure to Diagnose

Failure to diagnose or delay in diagnosis are the major causes for lawsuits against primary care physicians. High-risk areas include heads (neurologic events, CVAs, and meningitis), hearts (the triple-rule-out), guts (missed appendicitis, ischemic bowel, etc.), severe infectious diseases and cancer. Colon cancer is currently the most common cause of litigation for delayed diagnosis of cancer, followed by breast, prostate and lung cancer and melanoma.

Lessons Learned:

• Consider adding a problem list to each patient's chart.
• Address undiagnosed symptoms on the problem list each visit.
• Discuss with the patient items on the problem list; incorporate this information into each visit's Review of Systems.
• Establish a tickler system to order and communicate results of diagnostic and therapeutic modalities.

Potential Damages

Failure to diagnose or delays in diagnosis are major causes for lawsuits against primary care physicians. A physician may be held liable for injuries or losses that resulted from the delay or failure to diagnose, and defending against such claims can be time intensive and costly. Implementing thorough problem lists reduces the risks of missing or delaying a diagnosis, and thus reduces the risk of litigation.