btadlock1
Guest
Does anyone know the answer to this?:
*I know that CC, ROS, and HPI can be listed seperately, or can be included in an HPI description.
*I also know that the ROS is the patient's positive and negative responses to questions about the affected system, which is described in the HPI/CC and other related systems.
*And, I'm aware of the fact that the CC must be recorded by the physician.
Now here's a scenario to consider:
A practice uses an EHR template that includes a section labeled "Chief Complaint", followed by a section labled "History of present illness." The CC section is often populated by 're-recording' (sometimes copy/pasted or copy/forward). The provider does personally record the HPI portion, which is usually detailed enough to reiterate the CC. But, in one instance, the CC forwarded from the nursing entries doesn't match the ROS, HPI, Exam, or Plan.
"CC: pt here for follow up on labs for impotence; sore throat; congestion; cough."
Then the ROS and exam only focus on the ED, and actually say "No sore throat, No nasal congestion", and "no cough", and "Lungs CTA" and "no pharyngeal erythema".
Now for my questions:
Should we have the field carried over from nursing documentation labeled as "CC", when by definition, the info doesn't meet the documentation guidelines for a CC?
Secondly, what do you make of the nursing CC not matching the content recorded by the MD? Does it matter?
*I know that CC, ROS, and HPI can be listed seperately, or can be included in an HPI description.
*I also know that the ROS is the patient's positive and negative responses to questions about the affected system, which is described in the HPI/CC and other related systems.
*And, I'm aware of the fact that the CC must be recorded by the physician.
Now here's a scenario to consider:
A practice uses an EHR template that includes a section labeled "Chief Complaint", followed by a section labled "History of present illness." The CC section is often populated by 're-recording' (sometimes copy/pasted or copy/forward). The provider does personally record the HPI portion, which is usually detailed enough to reiterate the CC. But, in one instance, the CC forwarded from the nursing entries doesn't match the ROS, HPI, Exam, or Plan.
"CC: pt here for follow up on labs for impotence; sore throat; congestion; cough."
Then the ROS and exam only focus on the ED, and actually say "No sore throat, No nasal congestion", and "no cough", and "Lungs CTA" and "no pharyngeal erythema".
Now for my questions:
Should we have the field carried over from nursing documentation labeled as "CC", when by definition, the info doesn't meet the documentation guidelines for a CC?
Secondly, what do you make of the nursing CC not matching the content recorded by the MD? Does it matter?
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