documentation of an office visit

Colliemom

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Posting this for a coworker, we would appreciate your help.


What parts of the note can be done by a medical assistant. I think it can be the review of systems, but can it also be the medical/social/ history? My understanding is that the only part, of the history, that must be done by the provider is the history of the present illness. Is this correct?
 

btadlock1

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Posting this for a coworker, we would appreciate your help.


What parts of the note can be done by a medical assistant. I think it can be the review of systems, but can it also be the medical/social/ history? My understanding is that the only part, of the history, that must be done by the provider is the history of the present illness. Is this correct?
PFSH, ROS, and vitals for the exam can be documented by ancillary staff. Provider must document HPI, the rest of the exam, and the MDM. He should also reference entries made by others, to show that he reviewed the info. ;)
 
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