Pam Warren
True Blue
Other than this (in the CMS's E&M Services Guide, below)does anyone have regulatory guidance that points to whether or not ancillary staff may record HPI information in an EHR? Our physicians are thinking (with some mis-guided support from our EHR vendor) that this would be a big time-saver. I say that a physician must document his own HPI,but cannot find anything that comes right out and says that. We use NextGen's EHR (version 7.8). Anyone have supporting documentation (no opinions, please....I have a hundred of those!) in regards to documentation of history by a physican or qualified NPP only?? Thanks in advance!
Notes on the Documentation of History
❖ [FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Describing any new ROS and/or PFSH information or noting there has been no change in the information; and [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Noting the date and location of the earlier ROS and/or PFSH. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. [/FONT]
[/FONT][/FONT]
Notes on the Documentation of History
❖ [FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Describing any new ROS and/or PFSH information or noting there has been no change in the information; and [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Noting the date and location of the earlier ROS and/or PFSH. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. [/FONT]
[/FONT][/FONT]