Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance

The problem list is a key and required [1] element of both the paper record and EMR. Weed [2] and [3] popularized the use of the problem list in an influential book and papers. Benson et al [4] have argued that the “problem list and the medication record are particularly useful for providing an overview of patients’ significant diagnoses and treatments. If wellstructured, reliable, and consistent, they can also contribute substantially to the quality of patient care.” An accurate problem list facilitates automated decision support, clinical research, data mining, and patient care [4], [5] and [6]. The Joint Commission on the Accreditation of Healthcare Organizations [1] mandates maintenance of a problem list. The problem list can be a useful tool in both paper records and EMRs for organizing physician notes, making patient rounds, and “signing out” patients to covering physicians [7] and [8].