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Wiki Hpi

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terricox

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Drummond Island, MI
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Does anyone know where you can find information in writting on who is allowed to complete the HPI part in the EMR? Physician, MA or either?
 
Look in the 1995 or 1997 documentation guidelines. They are very specific. Trailblazer has some wonderful information as well on E/M documentation guidelines.
 
It is stated very clearly on WPS (don't know what state you are in) and I also believe on CMS that the physician must obtain the HPI. Only the ROS and PFSH can be recorded by an ancillary staff member.
 
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