Results 1 to 5 of 5

EMR Documentation - When documenting

  1. #1
    Default EMR Documentation - When documenting
    Exam Training Packages
    When documenting the history in an EMR can the nurse's name be the one who documented the history or does it have to the the MD?

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default
    We have two EMR's...one that records the authors name on the record itself and one that does not. Recently, I noticed that the HPI (on a couple of records) was recorded by the ancillary staff. I knew this because the name of the nurse was recorded not the provider. So to answer your question...If it pertains to the HPI, it needs to have the providers name listed. Ancillary staff can record the ROS and PFSH but not the HPI.

    Now...our other EMR doesn't print the name of the individual recording the information (example-who records the HPI). However, there is an internal audit trail that I can view to authenticate who actually recorded the HPI. Either way...it needs to have the provider's name attached to this information since it is a requirement for the provider to record the HPI.

  3. #3
    Default
    Rebecca,

    As it is now, our nurse records the HPI, PMSH and the physician records the rest. Your saying the physician has to record the HPI?

    Missy Rockvoan, CPC
    Billing Mgr
    Family Practice Associates of Lexington

  4. #4
    Default
    Yes, that is correct. See the 1995 or 1997 E/M documentation guidelines. All this is spelled out for you. You can get them from the CMS link below.

    http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp
    Walker Bachman, CPC, CPPM

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by mrockvoan View Post
    Rebecca,

    As it is now, our nurse records the HPI, PMSH and the physician records the rest. Your saying the physician has to record the HPI?

    Missy Rockvoan, CPC
    Billing Mgr
    Family Practice Associates of Lexington
    Correct. The HPI can not be delegated to ancillary staff.

    In addition to Walkers reference to the DG's...below are some other links for your review.

    Q 19. Who can perform the History of Present Illness (HPI) portion of the patient's history?

    A 19. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.

    http://www.wpsmedicare.com/part_b/ed...ahistory.shtml

    http://www.codapedia.com/~article_11...e%20HPI%3F.cfm

Similar Threads

  1. Documentation on correct documentation placement of procedure notes in the EMR
    By ashephard in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-25-2014, 04:36 PM
  2. EMR Documentation Issue
    By AB87 in forum Medicare Regulations
    Replies: 4
    Last Post: 05-21-2013, 12:14 PM
  3. EMR Documentation - When a provider documents
    By jheiser in forum Auditing General Discussion
    Replies: 1
    Last Post: 03-07-2011, 06:23 AM
  4. EMR Documentation - When documenting
    By mrockvoan in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 01-13-2010, 09:37 AM
  5. EMR procedure documentation
    By Lisa Bledsoe in forum Auditing General Discussion
    Replies: 10
    Last Post: 07-17-2009, 10:17 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.