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Wiki "see hpi" ?

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rryder1963

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The practice I work for has an EMR and I am responsible for performing chart reviews (audits). I really do not get picky with the doctors/nurisng staff about how they wish to document the HPI (narrative, fill in the form, what have you); however, there is one item I just feel in inappropriate and it is spreading to other elements of the PFSH. Some staff insist on tapping the "button" that denotes "SEE HPI" under the ROS heading. Somtimes there is more information under the ROS, sometimes not. Now I'm seeing it under the Social Hx element of the PFSH (as in smoking).

It was my understanding that insurances really do not look favorably on this "See HPI" notation as it really doesn't take a whole lot to tap the stylist NOR does it take considerable effort to use the stylist to tap on pertinent ROS as dicatated by the CC and/or HPI.

What is the general feel about this out there? Does any other practice have a documentation guidelines for E/M charting in EMRs?

Thanks-
Wondering
 
We use EMR also, I have one physician that frequently states "HPI and ROS as stated in the HPI". I still only allow the physician credit either for an element of the HPI or of ROS as stated in the HPI, not both.
 
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