Certified Risk Adjustment Coder (CRC)

When should a problem list in EHR be updated?

1. Only when new problems emerge.

2. When previous visit information is carried over.

3. Regularly to reflect current patient problems.

4. Only at the start of each year.

The correct answer is: Regularly to reflect current patient problems.

Updating the problem list in the Electronic Health Record (EHR) regularly to reflect current patient problems is essential for maintaining accurate and comprehensive patient records. It ensures that healthcare providers have access to an up-to-date summary of the patient's health status, which is vital for effective decision-making, treatment planning, and care coordination. Regular updates are crucial because patient conditions can change frequently due to various factors such as new diagnoses, changes in symptoms, or the resolution of previous conditions. An accurate problem list allows healthcare providers to identify trends in a patient’s health over time and manage chronic diseases more effectively while also complying with documentation standards that support risk adjustment and reimbursement. Having an up-to-date problem list is also important for proper coding and billing, as it directly impacts the capture of clinically relevant diagnoses and promotes continuity of care among different providers and settings. Regular documentation and updates ensure that all healthcare professionals involved in a patient's care are informed of any changes in their health status, ultimately improving patient outcomes.