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Wiki Chief Complaint/HPI in visits for routine PNC

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clynntarpley

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At the practice I work for, we have the worst time with proper documentation.

I have one doc in particular that, for his routine obstetric visits, completely leaves off the chief complaint and HPI portion of the note.

I've googled and googled but can't seem to come across anything specific with regard to CC/HPI.

I know that in regard to wellness/preventive visits, no chief complaint is necessary. Does this by any chance apply to routine prenatal care?

Any light anyone could shed on this for me is so greatly appreciated!

Thank you!
 
clynntarpley said:
At the practice I work for, we have the worst time with proper documentation.

I have one doc in particular that, for his routine obstetric visits, completely leaves off the chief complaint and HPI portion of the note.

I've googled and googled but can't seem to come across anything specific with regard to CC/HPI.

I know that in regard to wellness/preventive visits, no chief complaint is necessary. Does this by any chance apply to routine prenatal care?

Any light anyone could shed on this for me is so greatly appreciated!

Thank you!
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Yes ACOG has a great reference concerning this for prenatal visits you don't have to reach the detail bulletin points needed for EM as well as possible Chief complaint is not needed but Google ACOG guideliness on this
 
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