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Documenting Chief Complaint and Subjective

  1. Default Documenting Chief Complaint and Subjective
    Medical Coding Books
    Hello All,

    I know this will sound like a silly question, but hey someone has to ask it.I have a question regarding documenting the Chief Complaint and Subjective in the patient’s chart. We have recently upgraded in our office to a new EMR. When our nurses start the chart they take the Chief Complaint and the Subjective. When they document that information their name shows up on that part of the documentation to show that they took that information and entered it into the chart. Is that going to be a problem if we were to have an audit? The note is completed and signed off on by the Dr., but we do not want to be documenting incorrectly. I hope that someone will be able to help answer my question. Thanks for your time.


  2. Default CC
    This was discussed at a seminar I attended recently. If the MA documents the CC, it is fine but the HPI must be documented by the physician. As long as it clearly shows the main components of the exam were documented by the provider, you're OK.

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