Wiki Chief complaint (carry forward) by ancillary staff

[isleflow0r]

My provider argues that if he is consciously carrying forward Chief Complaint gathered by ancillary staff that he is reviewing it and it should be accepted (without notation).

Would this count as having any validity being that the information was obtained by ancillary staff initially? Shouldn't there be a notation at least to state that he/she reviewed it for accuracy and that he/she performed it and adding to it if necessary?

Is there anything from CMS aside from the Noridian link (https://med.noridianmedicare.com/web/jeb/specialties/em/clarification) which has more clarification? There is argument that this mainly pertains to HPI and that it is only the HPI that should have a notation for reviewed for accuracy, did perform it and adding to it if necessary. Does this also apply to Chief Complaint?

Can I advise my provider that carrying forward the Chief Complaint is not recommended without notation or he should be documenting the chief complaint himself?

 

[CatchTheWind]

I have been told that the act of signing the note implies that the provider reviewed the HPI for accuracy and made whatever additions and changes were necessary. This should certainly apply to the CC, as well.

 

[isleflow0r]

My provider argues that if he is consciously carrying forward Chief Complaint gathered by ancillary staff that he is reviewing it and it should be accepted (without notation).

Would this count as having any validity being that the information was obtained by ancillary staff initially? Shouldn't there be a notation at least to state that he/she reviewed it for accuracy and that he/she performed it and adding to it if necessary?

Is there anything from CMS aside from the Noridian link (https://med.noridianmedicare.com/web/jeb/specialties/em/clarification) which has more clarification? There is argument that this mainly pertains to HPI and that it is only the HPI that should have a notation for reviewed for accuracy, did perform it and adding to it if necessary. Does this also apply to Chief Complaint?

Can I advise my provider that carrying forward the Chief Complaint is not recommended without notation or he should be documenting the chief complaint himself?

I have been told that the act of signing the note implies that the provider reviewed the HPI for accuracy and made whatever additions and changes were necessary. This should certainly apply to the CC, as well.

According to the above link by CMS the provider should have notation in regards to HPI for accuracy, did perform it and adding to it if necessary. I am thinking this should apply to CC as well.