I was told that the doc must document this in his own writing and words. We have the same situation at our practice and our docs were just checking a box staying he reviewed and confirms the above note, which the nurse documented and apparently this is not allowed. Our MAC states the doctor must collect the HPI, not the ancillary staff, only the ROS and PFSH can be done by other staff or patient questionaires....so our docs are now being retrained!
Other thoughts on this would be interesting!
Jodi Dibble, CPC
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