Understanding Problems Record Status

When adding a problem to a patient’s chart, you’ll assign two types of status: Clinical Status and Verification Status. These statuses work independently but together give a clear picture of the patient’s condition and your diagnostic certainty.

Clinical status

Clinical Status reflects the current state of the condition.

• Active: The patient is currently experiencing the condition, or it remains clinically relevant.
• Inactive: The condition is no longer present and not currently affecting care.
• Recurrence: The condition returned after being fully resolved.
• Relapse: The condition worsened again after a period of improvement or remission.
• Remission: The condition is controlled but may return.
• Resolved: The condition is fully healed with minimal risk of returning.
• Unknown: The current status cannot be determined.

How to use clinical status

• Use Active or Inactive as general statuses when needed.
• Use Recurrence or Relapse when you want to be more specific about an active condition.
• Use Remission or Resolved when refining an inactive condition.

Verification status

Verification Status reflects how certain you are about the diagnosis.

• Unconfirmed: Not enough information yet (default for new problems).
• Provisional: Suspected diagnosis, still being evaluated.
• Differential: One of multiple possible diagnoses under consideration.
• Confirmed: Diagnosis has been established.
• Refuted: Diagnosis has been ruled out.
• Entered in Error: Record was added incorrectly and is no longer valid.

How the statuses work together

Clinical and Verification statuses can be combined based on the situation.

Common examples:

• New symptoms under evaluation → Active + Provisional
• Diagnosis confirmed → Active + Confirmed
• Condition under control → Remission + Confirmed
• Condition fully healed → Resolved + Confirmed
• Diagnosis ruled out → Inactive + Refuted

Set or update status

1. Open the patient chart and go to Problems.
2. Add a new problem or edit an existing one.
3. Select a Clinical Status.
4. Select a Verification Status.
5. Click Save.

New problems default to Unconfirmed. Update the status as more information becomes available.

Delete a problem

Deleting a problem does not permanently remove it.

• The Verification Status is automatically set to Entered in Error
• The problem is hidden from the default view
• The record remains for audit purposes

Problems marked as Entered in Error cannot be edited or deleted again.

Filter problems by status

You can filter the problems list using Clinical Status and Verification Status filters at the top of the table.

This helps you quickly focus on:

• Active conditions
• Confirmed diagnoses
• Or any combination relevant to your workflow

Keeping these statuses updated ensures your problem list remains accurate and clinically meaningful.