Golden Thread: Problem List

To begin Golden Thread documentation for a patient, start by listing the problems identified using the Problem List evaluation type. Because evaluations can be customized by each facility, the name and patient chart location of this evaluation will vary. 

Click here for instructions on building a Golden Thread Problems List Template. 

Document Patient Problems

To document the patient's problems:

1. Open the patient chart tab containing the golden thread problems list evaluation.
2. Click Add form.
3. Select the problem list evaluation by clicking Add.
   
4. Click the Edit icon to open the form.
5. From the Problem List field, there are a few ways to enter problems.
6. Click on the List icon to open a Problem list window containing the problems included in the Golden Thread content.
7. Select one or more problems from the list, then click Submit.  
8. You can also begin typing in the Problem List field and select the matching problem from the drop-down.
   • If you don't find a matching problem, you can free-type it in as well. 
9. Click Add Problem.
10. Additionally, you can use the Possible problems based on current diagnoses button to review problems tied to the diagnosis codes added to the patient chart.
11. You can select one or more options from the pop-up and click Submit to add.  
12. Once the patient's problems have been documented, you can add optional Behavioral Definitions. These are optional.
13. If you've chosen problems tied to specific definitions, you can use the content icon to select definitions.
    
14. Select any applicable definitions from the pop-up, then click Submit.
15. You can also free-type in definitions as desired. 
16. Finally, select a status for each of the problems identified. Options include:
    
• Active: This is a problem that you plan on treating. This field allows you to create a treatment plan. 
• Completed: This problem has been treated and successfully completed.
• Deferred: This problem will be addressed later or by another facility. You will not be able to create a treatment plan for this problem. 
• Referred: The patient has been referred to the facility to treat this problem. This field allows you to create a treatment plan. 
• Not Completed: The patient has been treated for this problem, but the problem is still ongoing. 
17. Next, collect signatures for the document. 

Once the patient's problems have been listed, you can create a treatment plan for any of the problems marked as Active, Referred, Completed, or Not Completed. Click here for instructions.