Should an implant be documented as a problem or history item?

Question: Is it best to draw attention to an implanted medical or surgical device by adding it to the problem list or to the surgical history list?

Context: Medical or surgical devices may be attached to or implanted within a patient. These are important to document in a structured way, as this facilitates use of the information in clinical decision support and awareness during relevant interventions. For example, that a patient has an artificial hip matters when selecting the type and duration of antimicrobial therapy for septic arthritis; that a patient has an inferior vena cava filter is essential to know when considering interventional radiology procedures or angiography.

Answer: The answer is neither the problem list or the surgical history list. There is a dedicated place where information about devices and implants should be documented.

The "Devices & Implants" section of the "History", "Problem List" and "Problem Oriented Charting" activities gives easy access to tools for adding, updating and removing relevant information. The same functionality can be accessed via a global (chart) search for "Implant" and then selecting "jump to implants". 

With the "Devices & Implants" tool open, first see if the object of interest has already been documented. If not, use the "New Implant" button to start the documentation process.


The data capture interface that appears may be intimidating, with many details that could be entered. Detail matters most for devices requiring regular surveillance until an anticipated explantation date. For other objects, it is sufficient to indicate the type of implant, name, status and insertion date. If no appropriate category appears in the pick-list for implant types, then that field can be left empty and a descriptive name entered for the device or implant of interest.

Device and implant data is incorporated into standard documentation objects (e.g., admission history & physical, discharge summary) and can be added to other documentation with the ".DEVICEHXT" SmartLink.

In general, the existence of a device should not be documented in the problem list or in the surgical history section of the chart. Those sections might appropriately reference an entry in the Devices & Implants list when relevant to another problem or health event.

2 comments:

  1. Jacques RomneyAugust 17, 2021

    I would think that the surgical procedure associated with the device implementation should still be recorded in the surgical history.

    ReplyDelete
  2. Yes, I would agree. The hip replacement, for example, would be added to the surgical history and the particulars of the implant (artificial joint or pin type) would be added to the devices and implants history.

    ReplyDelete

Please feel free to offer additional perspectives and suggestions.