Wiki HPI part of exam

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aclinton

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Can anyone out there tell me who is supposed to perform the HPI part of the exam? I thought it was the provider but am starting to have some people tell me that anyone can document it. Thanks in advance.
 
Hpi

Per documentation guidelines the HPI must be performed by the provider. You can find this in the '95 and '97 guidelines as well as the CMS,OIG guidelines.
 
What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an Evaluation and Management encounter? Can ancillary staff act as a scribe for a provider?

Ancillary staff may ONLY document:

Review of Systems (ROS)
Past, Family, and Social History (PFSH)
Vital Signs
These three areas MUST be reviewed by the physician or NPP who MUST write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can PERFORM the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances an Office or Emergency Room triage nurse may document pertinent information regarding the Chief Complaint/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

Scribe (E/M Services):

If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed, and sign his/her name. The name of the scribe must be identified

There are times when Palmetto's link doesn't work but I'll supply it just in case...

http://www.palmettogba.com/palmetto...Questions~EM~D94D5E1AD8A36256852574BB007CFE9F
 
The HPI is the only component of History that must be personally obtained by the provider. The CC, ROS, and PFSH may be obtained by other ancillary staff. I do have some physicians that prefer to obtain the ROS as apart of his/her HPI. However, this is their preference, and is not required. If a questionnaire form is used to obtain the history, the physician must reference this in his/her dictation that he/she reviewed the information with the patient.
 
"The HPI is the only component of History that must be personally obtained by the provider. The CC, ROS, and PFSH may be obtained by other ancillary staff. I do have some physicians that prefer to obtain the ROS as apart of his/her HPI. However, this is their preference, and is not required. If a questionnaire form is used to obtain the history, the physician must reference this in his/her dictation that he/she reviewed the information with the patient."
__________________
-AR-
CPC, CPC-E/M, CPMA

AR,

Interesting that you state ancillary staff can document the CC. I have been told the exact opposite.

Ancillary Staff and Patient Histories
Q What portion of a visit can ancillary staff perform and document? Can they perform and document the history of present illness (HPI) or chief complaint (CC) if I read their documentation and notate that I have done so and agree with it?

A According to the 1995 and 1997 E&M documentation guidelines, the only portions of the history that may be recorded by the ancillary staff of a physician are the Review of Systems and Past/Family/Social History, and those portions must be reviewed by the physician. The physician must also write a statement supplementing or confirming the information recorded by the ancillary staff.

CMS recently clarified that only the physician or nonphysician practitioner who is conducting the E&M visit can perform the HPI and CC, stating that this is physician-level work and shall not be relegated to ancillary staff. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded, or scribed, and write a notation that she reviewed it for accuracy and did perform it, adding to it if necessary and signing her name.

http://www.physicianspractice.com/index/fuseaction/articles.supplementDetails/articleID/1196.htm

Also-
Who can perform and document the chief complaint?

Per the Documentation Guidelines, the chief complaint is required for all levels of history and must be clearly reflected in the medical record. Ancillary staff cannot perform and document a chief complaint (CC). The CC is part of the HPI, which must be performed by the physician.

http://www.wisconsinmedicalsociety.org/education/faq#q16

Thoughts?
 
Last edited:
hmmmmmmmmmmmm...... well i may have learned something new today! I have always always always been told that the ancillary can document the CC... the provider documents the HPI which is driven from the CC.

Let me see what I can come up with.:)
 
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