Problem Lists and Medications

The problem list and medication list give clinicians a current snapshot of a patient’s active conditions and prescriptions.

Every patient record in DPC Pro includes a problem list and a medication list. These lists are maintained by clinicians and updated during visits. They serve as a quick reference for anyone on the care team who needs to understand the patient’s current health status.

This page covers how to add, edit, and resolve problems on the problem list, as well as how to manage active and discontinued medications. Both lists are visible from the patient record and can be referenced while writing visit notes.

Keeping these lists current improves care quality, maintains continuity when multiple clinicians treat the same patient, and supports HIPAA compliance requirements for accurate medical records.

Add a Problem

Problems represent active conditions, chronic diagnoses, and other ongoing clinical concerns for a patient. DPC Pro tracks problems using ICD-10 codes and free-text descriptions.

Adding a Problem During a Visit Note

The most common way to add a problem is while writing a visit note:

1. Open the visit note for editing.
2. In the Assessment section, select Add ICD-10 Code.
3. Search for the condition by typing at least two characters of the ICD-10 code or a description keyword.
4. Select the appropriate code from the search results.

The code appears as a tag in the Assessment section of the note. Codes added to visit notes are associated with that specific encounter.

Search Tips

You can search by code prefix (for example, E11 for type 2 diabetes codes) or by description (for example, hypertension). The search returns up to 20 matching results, sorted by code.

Adding a Problem from the Patient Record

You can also manage the patient’s problem list directly from their medical history:

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Add chronic conditions to the conditions list.
4. Save your changes.

Conditions recorded in the patient’s medical history appear in the note editor sidebar when writing visit notes, giving you a quick reference during documentation.

Manage the Problem List

Viewing Active Problems

A patient’s active conditions appear in multiple places across DPC Pro:

• Patient record: the Medical History section shows all chronic conditions as labeled tags.
• Note editor sidebar: the patient context panel on the left side of the note editor displays the patient’s conditions under the Conditions heading.
• Visit note Assessment section: ICD-10 codes attached to the current note appear as tags in the Assessment section.

Removing a Diagnosis Code from a Note

To remove a diagnosis code from a specific visit note:

1. Open the note for editing (the note must not be signed).
2. In the Assessment section, find the code tag you want to remove.
3. Select the remove button on the code tag.

This removes the code from that specific note. It does not affect the patient’s broader medical history.

Editing the Conditions List

To update the patient’s chronic conditions list:

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Add, reorder, or remove conditions as needed.
4. Save your changes.

Notes vs. Patient Record

Diagnosis codes on a visit note document what was addressed during a specific encounter. The conditions list in the patient’s medical history is a standing record of ongoing problems. Both serve different purposes. Keep them updated for accurate clinical documentation.

Add a Medication

DPC Pro tracks medications both as prescriptions linked to visit notes and as a standing list in the patient’s record.

Adding a Prescription During a Visit

Prescriptions can be created and linked to a visit note. Each prescription captures:

• Medication name and strength
• Dosage form (tablet, capsule, liquid, etc.)
• Directions for the patient
• Quantity to dispense
• Days supply
• Number of refills
• Preferred pharmacy
• Dispense as written preference

Prescriptions linked to a visit note appear in the note detail under Linked Prescriptions, showing the medication name, strength, directions, quantity, refills remaining, and status.

Adding a Medication to the Patient Record

For medications managed outside of DPC Pro (prescribed by other providers, over-the-counter medications, supplements):

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Add entries to the Current Medications list.
4. Save your changes.

These medications appear in the note editor sidebar under Current Medications during visit documentation.

Manage the Medication List

Viewing Active Medications

Active medications appear in several places:

• Patient record: the Medical History section lists all current medications.
• Note editor left sidebar: the patient context panel shows up to five current medications from the patient’s record.
• Note editor right sidebar: the context panel shows up to five active prescriptions with their medication name, strength, and dosage form.
• Note detail: prescriptions linked to the note are displayed with full details including directions, quantity, refills, and status.

Prescription Statuses

Prescriptions move through the following statuses:

Status	Meaning
Draft	Prescription has been created but not yet sent to a pharmacy
Sent to Pharmacy	Prescription has been transmitted to the patient’s pharmacy
Filled	Pharmacy has confirmed the prescription has been filled
Cancelled	Prescription has been cancelled and is no longer active

Editing the Medications List

To update the patient’s standing medication list:

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Update the Current Medications entries.
4. Save your changes.

Allergies

Review the patient’s allergy list before adding or prescribing medications. Allergies are prominently displayed in the note editor sidebar in a highlighted panel, and in the right-side context panel during visit documentation. If your practice uses the AI assistant, it can flag potential allergy interactions when medications are added.

Problem and Medication History

Reviewing Visit-by-Visit History

Each visit note preserves a snapshot of the diagnosis codes and prescriptions associated with that encounter:

• Diagnosis codes: ICD-10 codes appear in the Assessment section of each signed note.
• Prescriptions: medications prescribed during the visit appear in the Linked Prescriptions section of the note detail.

To review a patient’s clinical history across visits:

1. Navigate to Clinical Notes.
2. Filter by the patient’s name to see all notes.
3. Open individual notes to review diagnosis codes and prescriptions from each visit.

Allergies

Allergies are recorded in the patient’s medical history and appear prominently in the clinical workflow:

• In the note editor left sidebar, allergies are displayed in a highlighted panel at the top of the patient context. If no allergies are recorded, the panel displays “NKDA” (no known drug allergies).
• In the note editor right sidebar, allergies appear with a warning indicator.

To update a patient’s allergy list:

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Update the Allergies entries.
4. Save your changes.

Surgical History

Surgical history is also tracked in the patient record and visible during note writing:

1. Navigate to Patients and open the patient’s record.
2. In the Medical History section, select Edit.
3. Update the Surgical History entries.
4. Save your changes.

Surgical history entries appear in the note editor sidebar for reference during visits.

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Related Pages

• Write Visit Notes
• Patient Timeline and History
• Print and Share Records
• Patient Records

Need Help?

If you run into issues with problem lists or medications, reach out to the DPC Pro support team at [email protected] or visit the troubleshooting guide.