Q&A: Educating providers on problem list usage

Q: How should CDI professionals work with providers to educate them on appropriate problem list usage?

A: Ultimately, for conditions that should be resolved upon discharge, it’s important for providers to update those problems lists in the discharge summary. Doing so prevents the diagnosis from being carried over to the patient’s ambulatory list of active problems. If we can educate our providers to document a resolution of acute conditions at discharge, these conditions do not pass to the patient’s active chronic problem list and these diagnoses are not used inadvertently post-discharge. 

It would be ideal to have the hospital active problem list updated upon discharge. But we all know this does not occur 100% of the time, so we have this never-ending cycle of needing to clarify the problem list during the next inpatient visit. 

Another way to combat this issue: It would be helpful if providers included the date of service on their diagnoses listed on the problem list. Otherwise, it appears as though the diagnosis is current. This would eliminate the confusion, and they won’t be receiving a clinical validation query for clarification.

CDI teams can work with providers to help establish good documentation practices that support these requirements in a consistent and concise manner. One simple approach we can utilize in education is the term DEEP, which stands for:

• Diagnosis (What is the diagnosis?)
• Etiology (What is the cause of the diagnosis? Where did it originate? Why did it originate? Etc.)  
• Evidence (provide that evidence to support the diagnosis)
• Plan (this is when and where we look a little further to implement the MEAT criteria of Monitoring, Evaluation, Assessment, and Treatment.) 

Editor’s note: This question was answered by Lynette Byerly, BSN, RN, CCDS, CCS, a clinical documentation education specialist with ACDIS/HCPro, on the November 5, 2025, episode of the ACDIS Podcast.