chief complaint in ehr world

jmcalister

Contributor
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Ok my question is who should put in the chief complaint. Usually the nurses at our put the chief complaint in their assessment. In a copy and paste world does it still count if the doctor copies and pastes that into the dictation. We have some new docs at our facility and some labs were ordered, I sent message stating we cannot code rule out signs and symtoms would be appropriate. He said reason for the lab was in the chief complaint. Great but did he take the chief complaint or the nurse?

Any information would be appreciated all I can come up with is the definition of a chief complaint.

Thanks
 

mitchellde

True Blue
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13,430
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Columbia, MO
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The chief complaint is the patient's statement as to what they feel is the problem, the signs and symptoms need to come from the provider in his exam. I have never coded from the chief complaint.
 

CBaer

Networker
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Harrisburg PA
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Documentation of CC

The CC is to be documented by the provider rendering and billing for the service. If you look at the documentation guidelines, under the "General Principles of Medical Record Documentation" it state, "the amount of physician work".

If you read the actual guidelines it indicates the areas that someone other than the provider can document, specific areas ie ROS, PFSH and Vitals. There are no other provisions within the guideline that allows documentation from others.

If you are using a scribe this must be stated in the providers documentation...check with your local carriers on the required documentation on using a scribe.

Hope this helps.

Cheryl
 
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