Wiki EMR Documentation - When documenting

[mrockvoan]

When documenting the history in an EMR can the nurse's name be the one who documented the history or does it have to the the MD?

 

[RebeccaWoodward*]

We have two EMR's...one that records the authors name on the record itself and one that does not. Recently, I noticed that the HPI (on a couple of records) was recorded by the ancillary staff. I knew this because the name of the nurse was recorded not the provider. So to answer your question...If it pertains to the HPI, it needs to have the providers name listed. Ancillary staff can record the ROS and PFSH but not the HPI.

Now...our other EMR doesn't print the name of the individual recording the information (example-who records the HPI). However, there is an internal audit trail that I can view to authenticate who actually recorded the HPI. Either way...it needs to have the provider's name attached to this information since it is a requirement for the provider to record the HPI.

 

[mrockvoan]

Rebecca,

As it is now, our nurse records the HPI, PMSH and the physician records the rest. Your saying the physician has to record the HPI?

Missy Rockvoan, CPC
Billing Mgr
Family Practice Associates of Lexington

 

[Walker22]

Yes, that is correct. See the 1995 or 1997 E/M documentation guidelines. All this is spelled out for you. You can get them from the CMS link below.

http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

 

[RebeccaWoodward*]

Rebecca,

As it is now, our nurse records the HPI, PMSH and the physician records the rest. Your saying the physician has to record the HPI?

Missy Rockvoan, CPC
Billing Mgr
Family Practice Associates of Lexington

Correct. The HPI can not be delegated to ancillary staff.

In addition to Walkers reference to the DG's...below are some other links for your review.

Q 19. Who can perform the History of Present Illness (HPI) portion of the patient's history?

A 19. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

http://www.codapedia.com/~article_118_Who can document the HPI?.cfm