Eli's Rehab Report
READER QUESTIONS:
Heads-Up--Physician Should Document HPI
Published on Mon May 08, 2006 
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Question: If a nurse documents the history of present illness in her notes and the physiatrist documents that he read the notes and agrees, can we count this as the physician's HPI? Or must the physiatrist perform the HPI himself? Answer: According to Medicare's 1995 Documentation Guidelines, the physician must personally perform the HPI during an E/M visit.
Idaho Subscriber
Both the 1995 and 1997 guidelines state that ancillary staff (such as nurses) can perform other E/M history components, such as the review of systems and past family social history, but HPI is not listed among them.
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