Wiki Question about HPI & ROS & PFSH

[daniel]

Can ancillary staff fill out the ROS & PFSH when they meet with the patient first. I beleive so.

And regarding the HPI, I'm under the understanding that the physician must fill this out his self. But I recently read an article that stated that if the ancillary staff does the HPI ahead of time, the physican can add to it or address that he concers with it.

What does the coding world think.

 

[Lisa Bledsoe]

The HPI MUST be in documented by the provider. Concurring with what the ancillary staff has documented is not enough. Documentation must support that the provider took the actual HPI.
Lisa

 

[grahamki]

In our practice ( which is a teaching facility) the Medical Student can do the Review of Systems and Past, Family, and Social BUT the provider has to concer and state that they have reviewed what the student has done and either agree or add to it. But the provider has to do the Physical Exam, HPI and the Assessment. This is where I have problems with my staff physicians because they want to let the medical student do ALL of the work and then just come in make notations for MDM. And they actually try to be tricky and not let the student sign the note and then the staff signs as if they had done all of the work, but they forget that I read ALL of the note and can tell there are two different handwritings. So yes they can do the ROS and the PFS but the physician HAS to refer back to it and make notations that they reviewed and agree or add to it.

Kim Moore, CPC

 

[RebeccaWoodward*]

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.


http://www.intelicode.com/HCFAguidelines.htm



Hope this helps~Rebecca

 

[codegirl0422]

Ancillary staff can fill out the ROS & PFSH as log as the provider initials the intake questionnaire etc that they reveiwed it and they should add any additional pertinent information as necessary.

The HPI must always be completed by the phyisican/provider.

For documentation: http://www.emuniversity.com/CodingGuide.html

Can ancillary staff fill out the ROS & PFSH when they meet with the patient first. I beleive so.

And regarding the HPI, I'm under the understanding that the physician must fill this out his self. But I recently read an article that stated that if the ancillary staff does the HPI ahead of time, the physican can add to it or address that he concers with it.

What does the coding world think.