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in this video we're going to document the process for a specialist or any medical provider for that matter to document a medical problem and add it to the patient's problem list we will also then go over the method for them removing it from the problem list but adding it to the patient's past medical history for historical purposes as well as documenting any surgical or procedural intervention which may have been performed in this example I'm going to give this patient and diagnosis of gall stones I searched for it I'm going to choose this one notice that once I've added it there's this box that says PL PL means problem list so if I check this then it will remain on the problem list forever or until another provider goes ahead and removes it in this case I'm assuming the role of a general surgeon who's seeing a patient in consultation for gall stones I've seen them at the visit I've documented that they have gall stones I can also this moment make some diagnostic specific notes if I click on this box a new window will open and now I can write the information in this case I've quickly added some information showing that the ultrasound document of the gall stones and we're doing to do a laparoscopic cholecystectomy the next week and this information will stay on there now I've added this it's on the problem list as well as my office visit now I haven't done the rest of this problem or the assess the other problems in this note but I'm going to go ahead and lock it yes this is an incomplete note but that's okay now I'm going to go to the patient's office visit today which is here this is a new office visit so let's imagine that I have now seen this patient I've done their laparoscopic cholecystectomy and now I need to update this in their chart I'm going to go back here and I can find the problem list and I can add gall stones now I can document any information that I might need to notice I still have my ultrasound notes here and I can add or information and I'm going to click OK now I'm going to close this and I still need to do two things this patient no longer has gallstones so this is no longer an active medical problem for this patient and I don't want it on their problem list but I do want the historical information available showing that they were treated for gallstones and that they had the surgery so the first thing I'm going to do is go up to my surgical history and click on it there are two ways I can add this I can simply click Add now if I know the date that's really nice to have it's not required but it's a very nice thing to have so that's one way the other way is I can have this keyword box here and then I can click on the ellipsis box here and I can search for it in this case I've got all of my favorites showing it looks like I don't have that one shown as a favorite so I'm going to uncheck this and now you can see all of them and I could either scroll through to find it and there's cholecystectomy or I could search for it and find it either way now in this case I've added it twice I realized that doesn't quite make sense but those are both ways that you could add it also if I knew the cpt code for Kali cystectomy I could add it that way if I click CPT click the box then I could search for the code I don't know the code for close has decked me so I'm not going to add it that way now this is in my surgical history I'm going to hit go ahead and erase one because I don't need both of them in there now it's in my surgical history finally we need to remove this from the problem list because the patient no longer has gallstones and they shouldn't ever get them again because they don't have a gallbladder so I'm going to go to their overview and here you can see the problem list notice the gall stones are on well I want to save the information that I've done and move it all at one time so I'm going to click on the ellipsis button and I can see my medical history off of my problem list notice here's my notes still there I'm going to highlight gallstones in this case I'm going to click remove there is this copy to medical history button but that will put it in two places instead we click remove and it'll give you the option do you want to just remove it or what's recommended is remove it and add to the medical history that's what I want to do I remove it I add it to the medical history all with one click now if you look on the medical history we can see gall stones it's still in the problem list for today but once I lock this note gall stones are no longer going to be on the problem list in this way I have now documented gall stones at my first visit when I see them and follow up after the intervention I can still document the follow-up and I can document the surgical history and I can move gall stones of the problem list all at one time this is the recommended action for any medical specialist or primary care physician who's performing an intervention or procedure especially if it results in the diagnosis no longer being appropriate to be on the problem list but it should still be listed as part of their medical history another example might be someone with tonsil stones once they've had the tonsillectomy and it's removed they no longer have tonsil stones but I would like surgical history to show tonsillectomy and I would like their medical history to show the history of tonsil stones hopefully this was clear for you I would also recommend in the assessment box that you take advantage of this notes box in this example I've also added a diagnosis of coronary artery disease even if a person's had a bypass graft they're probably never considered cured of coronary disease so this is a really nice place that I can add a running commentary so I might put the initial visit coronary disease scheduled for stress echo and then when I see them back in two months positive stress echo ad by Paris graft surgery dr. Jones and then I can add another visit stress test and this is something that you can just add to on every visit and that can be quite helpful for those complex patients where you need to keep track of what has been done and have I done this before and these notes will remain there unless someone Rose them that also raises the question or the point that we work in a large multi-specialty group if you add or remove something you have added or removed it for everyone if you're the medical specialist taking care of that problem please add or remove or update that as appropriate if it's something that you don't deal with or don't have involvement in their care please just leave it alone because some other specialist in our group is taking care of it hopefully this has been beneficial for you