Wiki Chief Complaint/Status of Chronic Conditions

[beyondhope0322]

Does the chief complaint need to be separate from the HPI? There has been information out there that says that the chief complaint can listed under its own header or as the first sentence of the HPI (as long as it is clear). At my facility, many providers are split when doing this and I am trying to find out which is the correct way because it would alleviate a lot of extra work on both ends.


IF the chief complaint can be the first sentence of the HPI, would this suffice for chief complaint and status of one chronic condition? Example: Patient presents for follow up on hypertension and states he is doing well and offers no complaints.

Please let me know your input. Thank you very much.

 

[thomas7331]

The CMS documentation guidelines only state that "The medical record should clearly reflect the chief complaint." Having a separate header or section for the CC could be helpful to providers and/or coders to ensure that this is clear and not omitted from the note, but it is not a requirement in any official guidelines that I have ever seen that it be separate from the HPI.