EMR and HPI Experts...

RebeccaWoodward*

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I think we have established, in previous threads, that the chief complaint must be documented by the physician. For those of you already on an EMR system, what is your protocol for nurses/cma's taking the CC? Do you have your physician restate the CC or does your physician insert his/her name below the nurse/cma name (an indication that he has personally asked the patient and agrees with the nurse/cma's entry)?

Our EMR system has a "audit trail"; however, if the physician doesn't somehow, somewhere, notate the CC...how can we (I) prove that we are compliant?

I've presented this question to other auditors, educators...and we seem to agree what needs to be said and documented, but if anyone has any personal experience, I would love to hear it!
 
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Lisa Bledsoe

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We have EMR...when they came out to train, they told the staff that nurses could document HPI...well, I've had to re-train every single provider that THEY must personally document the HPI. If I see the nurses initials by the HPI, I won't count it. They are learning...:mad:
 

RebeccaWoodward*

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Thanks Lisa...that's what I felt might happen. The IT folks that are implementing this project agree with us. They have done their homework, too. It's going to interesting to see how this all unfolds.

Thanks again~
 

aguelfi

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Hey Lisa how is your Next Gen EMR. We have it as well but have only gotten as far as the EPM. We've had it for about a year and I think that the potential is good but there are days where I am gritting my teeth.
 

Lisa Bledsoe

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Hey Lisa how is your Next Gen EMR. We have it as well but have only gotten as far as the EPM. We've had it for about a year and I think that the potential is good but there are days where I am gritting my teeth.

The biggest issue I have with the EMR is that it does not guide the providers to choose 4th/5th digits for their ICD-9 coding. So the dx codes in the notes are 3 digits only...had to have that function disabled until NextGen fixes it. The docs aren't happy that they still have to use the book :eek: !! There are other issues as well, but I think people who have both the EPM and the EMR are getting along much better than we are...
 

mariselaa

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Help!!! Urgent Care NEW vs EST.

Our biggest concern at the moment re: Urgent Care New vs Established is does the same rules for a new and established patient apply to the urgent care setting. Or does new guidelines apply. A new patient is one who has NOT been seen by the same provider within the same specialty, within the same group in the past 3 years. I heard somwhere that Urgent care patients are Always considered new if they come in for a different problem????? I am really not sure about that! PLEASE HELP. ASAP.
I can be reached by email at
mammi99@hotmail.com
or my direct number at 1-951-354-3178

THANKS!!!!

Marisela Amador-CPC:confused:
 

ARCPC9491

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I had this exact scenario come up just now - we have MediNotes in 2 of our practices - currently the nurses are documenting the HPI. The EMR doesn't have the option to use initials. The nurses say, "Well the physician reviews what I put, makes changes, and signs that everything is accurate and how would anyone know who did it anyway?" - and the EMR trainers also told them to do it this way.

I realize what she is saying - but I don't feel right with it, I've explained the guidelines but I feel like it's a losing battle...How do I counter this???:confused:
 

Lisa Bledsoe

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That's a difficult situation, since WE all know the provider is the one that has to document the HPI... Does your EMR have an administrator that can look into the record and tell you who did what? The problem is as stated...once the provider does his/her thing, it most likely all generates with their name. Are they willing to take on the liability that what the nurse documented is completely accurate? I would make this situation known to the powers-that-be and keep it documented that you brought it up as an issue and do not agree with the situation. CYA!!
 
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