Wiki HPI Documentation

[WATSONC]

I do ER coding and have physicians who may document some HPI elements plus add this statement "have reviewed and agree with RN notes". My question is, if the physician doesn't have enough elements in their HPI documentation can I use the nurses notes to obtain more elements?

 

[jimbo1231]

Not for HPI

The HPI is considered physician documentation only. Other History elememts such as ROS can be a hybrid of physicin and nurse documentation with an oversite statement. But not the HPI.

Jim Strafford MCS-P CEDC

 

[WATSONC]

Thank you for your reply. Another questions, can I go back to the physicians and have them add the additional documentation in an addendum prior to coding the chart (these charts are EMRs)?

 

[Jacoder]

I've went back to the DR and asked him to fill in the missing information. I just try to make sure I do it right away so that the patients case is still fresh on his mind.

 

[jimbo1231]

Depends

Depends....

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Most ED Coding organizations do not do this. This is usually viewed as a compliance issue. So if the doc only documents 3 HPI and you return the chart looking for a fourth, what is the reason besides being able to code a higher level? I have seen one organization do this. They are very careful to make it clear that they are looking only to have charts complete based on the clinical presentation, not to code higher. Another issue is timing. If there is a way you can return these charts close to real time, it passes the compliance sniff test a bit more. Usually this is unrealistic unless you are coding on site. I've reccomended at times that someone is trained on site to audit charts. This might be worth doing.
Hope this helps.

Jim