Take a look at the documentation guidelines on CMS website. If you look at the beginning under the paragraph titled "General Principle of Medical Record Documentation" (page 3 of the 1997 DG or the bottom of page 1 to top page 2 of the 1995 DG)
"The principles of documentation listed below are applicable to all types of medical
and surgical services in all settings. For Evaluation and Management (E/M)
services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services."
The intent here is that the documentation is that of the "physician". Within the documentation guidelines it states that only the ROS, PFSH and vital can be documented by someone other than the physician. Therefore the CC and HPI are to be documented by the physician. If the physician does not document theguidelines state there must be a notation supplementing or confirming the information.
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the
information recorded by others.
Measurement of any three of the following seven vital signs: 1) sitting or standing blood
pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5)
temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)
I hope this helps.
