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Wiki Hpi

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dballard2004

dballard2004

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It has come to my attention that the providers at my clinics have been letting the nursing staff document the HPI. I am aware that CMS states that the HPI can only come from the provider. As coding educator, I have been given the task to send an e-mail out to the entire corporation stating that the HPI can only be documented by the provider. Does anyone have any suggestions on how to word this? Thanks.
 
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Hi Dawson,
I would quote directly from the documentation guidelines. In addition, I would cut and paste what ancilliary staff may document per the DG's, which is the Review of Systems (ROS), and Past, Family, and Social hx (PFSH). Here is the link to the '95 DG: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
Please refer to Page 5.
Good luck!
 
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