Wiki HPI elements other provider

[chasarmil]

I have a provider(family medicine) that a patient was transferred from inpatient psych to his service for a fever, etc. For my provider it would be an initial inpatient visit. My provider states reviewed inpatient psych note for H & P(this H & P was 3 weeks prior) and reviewed transferred note, but did not document a comprehensive History(only 3 HPI elements, 2 ROS, and no PFSH).

I'm trying to find information that he has to document his own History elements, but not finding this situation.

Any help would be greatly appreciated.

Thanks

 

[teresabug]

for proof for your provider, if you do not have this, download the 95/97 documentation guidelines from cms.hhs.org

 

[thomas7331]

The provider must perform their own HPI in all cases, but especially this one where the are seeing the patient for a new problem of fever that developed. The ROS and PFSH can be reviewed in the chart but the provider still needs to documented that they reviewed it with the patient and note any changes. We were recently cited in an audit because the provider only documented that they reviewed the ROS done by another provider and did not state that they agreed or disagreed with the findings, so no credit was given for this portion of the history.

 

[chasarmil]

Thanks for confirming what I already knew.
Sometimes I just need to get confirmation from someone else before providers will accept it.