Wiki HPI from patient history form

[melzinser]

My spine docs have the patient fill out an extensive history form at their initial visit. The doc then reviews it with the patient and makes notes on the form. Now they want to count that as the complete history portion of the exam. I’m OK with the ROS and PFSH in the patient’s handwriting with documentation (check box and initialing) that the provider reviewed it. I don’t feel comfortable that the doc's annotations on the HPI portion is valid. I always thought the HPI has to be in the provider’s words / handwriting / dictation. The docs’ rebuttal is if they “jot comments” or "circle" four statements by the patient, i.e., location, duration, severity, context, and initial it, that should be good enough.

I have supporting documentation from the CMS Guidelines that ancillary staff can only obtain ROS, PFSH & vitals. What I need confirmed is if the provider's initialing the patient's handwritten statement is sufficient documentation, or do they need to restate the HPI.

 

[bedwards]

This has been a hot topic the past few years. WPS is the J5 MAC for my area and I have copied what is on their website-obviously you need to check with you local carrier.

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/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml)

Q 21. If the nurse takes the HPI, can the physician then state, "HPI as above by the nurse" or just "HPI as above in the documentation"?
A 21. No. The physician billing the service must document the HPI.

Hope this helps,

 

[melzinser]

The physician will be documenting the HPI - they just want to put it in a box on the paper history form the patient completes in the waiting room. The idea is the physician would jot down comments while reviewing the patient-supplied information. I am concerned about it all being on the same form. Even if the physicians initial their entries, will it be clear to an auditor? I want the HPI to be on the rest of the progress note template, not on the patient-completed form.

 

[bedwards]

I see what you are saying and it could be problematic because if that form were not referred to in the documentation on a specific date of service, you could not use the information.