What is the proper method for writing a comprehensive medical problem list for a patient with multiple conditions, including hypertension, diabetes, and hyperlipidemia, and taking medications such as aspirin (acetylsalicylic acid)?

How to Write a Medical Problem List

A comprehensive medical problem list should include all active cardiovascular and non-cardiovascular conditions, be updated at every clinical encounter by the entire care team, and be maintained in an interoperable electronic health record system to promote effective interprofessional communication. 1

Core Components to Include

Cardiovascular Problems

• ASCVD conditions: Coronary artery disease, cerebrovascular disease, peripheral arterial disease 1
• ASCVD risk factors: Hypertension, hyperlipidemia, tobacco use 1
• Heart failure with specific ejection fraction classification 1
• Arrhythmias such as atrial fibrillation 1

Non-Cardiovascular Problems

• Metabolic conditions: Diabetes mellitus (specify type), obesity 1
• Renal disease: Chronic kidney disease with stage 1
• Hepatic disease: Chronic liver disease 1
• Neurological conditions: Cognitive impairment, dementia, stroke history 1
• Functional impairments: Fall risk, gait instability, incontinence 1
• Mental health: Depression, anxiety 1
• Musculoskeletal: Arthritis, chronic pain syndromes 1
• Malignancies: Active or history of cancer 1
• Geriatric syndromes: Polypharmacy, frailty 1

Systematic Approach to Problem List Creation

Step 1: Inventory All Active Problems

• Review existing documentation from all care settings and specialists 1
• Include both medical diagnoses and functional limitations that impact daily activities 1, 2
• Document complications of existing conditions (e.g., diabetic retinopathy, neuropathy) 1
• List social determinants affecting health when relevant (housing instability, food insecurity) 1

Step 2: Code Problems Appropriately

• Use standardized terminology (ICD-10 codes) where possible to enable clinical decision support 3, 4
• Allow free text when standardized codes don't capture clinical nuance 3
• Specify severity and stage for conditions like heart failure (NYHA class) or CKD (stage) 1

Step 3: Prioritize by Clinical Impact

• Rank problems based on their contribution to mortality, morbidity, and quality of life 1
• Identify conditions that can be addressed with therapies treating multiple problems simultaneously (e.g., SGLT2 inhibitors for heart failure, diabetes, and CKD) 1
• Consider time frame of benefit relative to patient's life expectancy, especially in older adults 1

Step 4: Update at Every Encounter

• Assign responsibility for problem list maintenance to the entire care team, not just physicians 1
• Add new diagnoses as they are identified 1
• Resolve or inactivate problems that are no longer active, maintaining historicity 4
• Document changes in problem severity or status 1

Integration with Medication Reconciliation

Problem list management must be paired with comprehensive medication reconciliation to identify prescription errors, duplications, and drug-drug interactions 1

• Request patients bring all medications (prescription, over-the-counter, supplements) or a complete list with names, doses, and frequency to every visit 1
• Cross-reference medications with active problems to identify missed opportunities or medications without corresponding diagnoses 1
• Check for duplicate therapies within the same drug class 1
• Assess for deprescribing opportunities when medications no longer match active problems or when polypharmacy burden is excessive 1
• Verify dosing adjustments based on renal function (eGFR) 1

Special Considerations for Multimorbidity

For Patients with Multiple Chronic Conditions

• Prioritize therapies that address multiple conditions simultaneously with high impact on mortality and quality of life 1
• Sequence treatments from highest to lowest patient value based on individual health priorities and feared complications 1
• Engage in shared decision-making to determine which problems matter most to the patient 1

For Older Adults

• Screen for geriatric syndromes including cognitive impairment, falls, depression, and functional decline 1
• Individualize screening for diabetes complications based on functional impact rather than applying universal protocols 1
• Consider life expectancy when determining which problems warrant aggressive treatment versus conservative management 1
• Document advance care planning discussions and goals of care 1, 5

Common Pitfalls to Avoid

• Failing to update the problem list at each encounter leads to inaccurate clinical decision support 1
• Omitting functional and psychosocial problems that significantly impact outcomes 1, 2
• Not reconciling medications with active problems creates missed treatment opportunities 1
• Ignoring patient priorities when sequencing treatment of multiple problems reduces adherence and satisfaction 1, 2
• Treating the problem list as static rather than a dynamic document that evolves with the patient's condition 1, 4

Electronic Health Record Best Practices

• Leverage EHR interoperability to share problem lists across care settings and promote care coordination 1
• Designate a problem list "owner" with ultimate accountability for accuracy 1
• Integrate problem list maintenance into clinical workflow rather than treating it as separate documentation 4
• Use the problem list to drive clinical decision support tools and population management 6, 4
• Enable multiple clinical views to support different specialties' perspectives on the same patient 4