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History of Present Illness

  1. Default History of Present Illness
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    Can a MA document the HPI or is it required that the Physician document the HPI? And is there a website I can use as the source. Thank you

  2. #2
    North Carolina
    The HPI must be documented by the Provider...

    Who can perform and document the HPI?

    The physician or NPP must personally perform and document the HPI.


    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.

    What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?Answer:

    Ancillary staff may only document:

    •Review of Systems (ROS)
    •Past, Family and Social History (PFSH)
    •Vital Signs

    These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

    Only the physician or NPP that is conducting the E/M service can perform the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff.


    !DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
    completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
    Rebecca CPC, CPMA, CEMC

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