melzinser
Networker
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.
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.