Wiki Can a nurse document Chief Complaint


Hot Springs, SD
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I have always been trained that the only person who can document the Chief Complaint is the provider. A nurse cannot document a chief complaint. I've researched here and most of the threads are older. Is there anywhere in CMS or OIG or anywhere that specifically says the provider must document CC? The CMS statement of what a nurse can document isn't being accepted by staff as statement that a provider has to document. Anything new regarding this yet?
This is the position of our MAC, Noridian, on who can document the chief complaint and HPI. If you have a different MAC, you may want to check their website to see if they have published any advice on the matter.

"Evaluation and Management Clarification

Per CMS, only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff.

Noridian Healthcare Solutions (Noridaian) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.

Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be "I have reviewed the HPI and agree with above."

Last Updated Aug 27, 2014"

Hope this helps!