Chief Complaint including HPI

Messages
6
Best answers
0
Question with using our EMR, when the patient is registered and chief complaint is documented by ancillary staff, sometimes there are also elements pertaining to HPI included. When our physician starts his note in the EMR, this documentation pulls into the physician note and then following this, the physician continues his documentation in regards to gathering more HPI. Question is, since this documentation is in/on the physician note, can elements of HPI be used from this documentation towards the physician billing level?

We "know" the physician didn't type it himself, however if he's pulled this complaint and additional info into his signed record, and there is no reference to the fact it may be RN's note, is it ok to continue to use toward HPI, if the doctor chooses not to retype the same information himself?

Would like your opinions, sometimes we get very technical here :) Thanks!
 
Top