Wiki Which documentation can I use?

[raidaste]

In my OBGYN clinic when a patient comes in for a visit (pre-op, Well Women, etc) the patient, nurse and physician all fill out a blue template that covers history, current, exam and plan. Sometimes the physician will then dictate a note too. She doesn't always include everything that was provided on the handwritten form in the dictation note. There's always more info in the handwritten than the dication and so my question is can I refer to both as I'm determining the level of E/M or making sure there's a comprehensive HPI and exam for the preventative visits?

 

[sageofthecode]

HPI by physician only

Hi Stephanie,

I'm currently studying for my CEMC exam. My OB/GYN practice just transitioned from paper charting to Athena EMR. As I undertand it, the physician MUST personally complete and record the HPI. The HPI is the ONLY part of the history which CANNOT be recorded by ancillary staff.

See also: http://www.emuniversity.com/HistoryofPresentIllness.html

Thanks,

Cathleen