On hospital day 10, the problem list still shows 'active pneumonia,' but imaging has cleared, antibiotics have been stopped, and current notes describe resolved pneumonia. What should the coder do when validating documentation?

EHR problem lists frequently persist through copy-forward and may not reflect current acuity. Coding validation requires reconciliation with progress notes, diagnostic studies, and treatment status during the encounter. An 'active pneumonia' label after documented resolution and cessation of therapy should not be coded as an active inpatient diagnosis without supporting contemporaneous provider documentation. Coders may report personal history or resolved status only when documentation supports that distinction.