Wiki Chief Complaint - HELP, please

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Cyndi113

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Good afternoon,

I'm new to a practice and have been attempting to get the providers to change their habit of documenting the chief complaint. All I'm receiving on most patients is 2 wk, 6 mo, or 1 year f/u. There is no other reason for the patient's visit. Is this adequate? It is not in the patient's words per Medicare's requirements.

Any help you can offer is greatly appreciated.
 
First of all, a chief complaint is required for all E/M.

The CC you listed are not going to be acceptable. We were advised to have our MA write Evaluation and Management of... and then ask the pt what they are being seen for... and then finish the statement E/M of headaches, 2 weeks, throbbing, etc.

This does not have to be in the patient's own words, but it does have to be there. The MD can complete the CC if the MA does not.

We have a joke that F/Us are not acceptable. :) Also, no BP checks, med refills, etc. You must have a sign, symptom, REASON for the visit. The dr said to F/U is not a reason. F/U for what? I had a cold last week... well then, "had a cold last week" is a CC or ask what symptoms are bringing them to the dr.

Hope that helps.
 
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What do their HPIs look like? If you don't have a separate chief complaint you can pull it from the HPI, of course you can no longer use that for an element of HPI but with out a chief complaint you can't have an E/M visit at all anyway.

Laura, CPC, CEMC
 
We have a specific spot on the chart note for the CC. If it is blank, it goes back, period. We don't let them pull from the HPI, because it's not really a CC then. IMO.
 
Thank you, Ladies!!

For the most part, most of the HPIs are adequate. However, I have one that does not complete an HPI for quite a few patients. All I get from him are patient here for test results (this is also listed as the CC) or med f/u (also listed as CC).

I appreciate your input.

Thanks again.

Cyndi
 
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