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Documentation for chief complaint

  1. Default Documentation for chief complaint
    Exam Training Packages
    Is it ok to only document 'no complaint today' or 'feels ok' under chief complaint?

    Also, I've read so much debate over who can document parts of the history, note, etc. but when it's all said and done, if the doctor's signature is on it-he reviewed everything and signed it and it's now a legal document signed by the physician-does it matter how the info got there?

    Amanda, CPC
    Urology coder

  2. #2
    Within our organization, we train the providers those statements are not usable for a chief complaint, even when we can "pull" it from their assessment. For some of our hospitalists, this is all the history they provide.... and then we ask...."why is the patient there" I would advise your providers to state "followup on CHF, patient has no NEW complaints...."or something to that effect.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  3. Default
    Speaking of pulling it from the assessment, I read that it has to be in the History portion. Not necessarily by itself like Chief Complaint: Chest pain-but at least in the HPI, ROS, somewhere in the history-not in the assessment, etc. Does that sound right or familiar?

    Amanda, CPC
    Urology coder

  4. #4
    Concord, NC or Rochester, NY
    If I were an insurance carrier auditor and the C/C was feels OK or no complaint today - I would ask what the medical necessity is and then ask for the money back. Almost every contract has the term Medical Necessity in it so there needs to be a C/C - even if it is f/u on a prior/chronic issue .

    Personally, I do not care who documents the Hx as long as the provider signs off on everything. The regs actually indicate the provider is suppose to document the ROS.

  5. #5
    Ellenville, New York
    Default CC is in the patient's own words
    The chief complaint is supposed to be in the patient's "own words" - so it would make sense that is should be documented somewhere in history. We gave our providers education on not using "feels okay" or similar vocabulary. If the patient "feels OK" and this is a scheduled F/U visit, then state that as such. After all, isn't that why the patient made the appointment - for the 2 week, 2 month, whatever FOLLOW UP?



    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  6. #6
    Harrisburg PA
    Take a look at the documentation guidelines on CMS website. If you look at the beginning under the paragraph titled "General Principle of Medical Record Documentation" (page 3 of the 1997 DG or the bottom of page 1 to top page 2 of the 1995 DG)

    "The principles of documentation listed below are applicable to all types of medical
    and surgical services in all settings. For Evaluation and Management (E/M)
    services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services."

    The intent here is that the documentation is that of the "physician". Within the documentation guidelines it states that only the ROS, PFSH and vital can be documented by someone other than the physician. Therefore the CC and HPI are to be documented by the physician. If the physician does not document theguidelines state there must be a notation supplementing or confirming the information.

    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.

    Measurement of any three of the following seven vital signs: 1) sitting or standing blood
    pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5)
    temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

    I hope this helps.

  7. Default
    Thank you guys.
    Lance, I code hospitalilists' visits so they see the patient every day for 3 days, 5 days, however long there in-so maybe I need to just get them to say No new complaint, f/u for diverticulitis, etc...or just their primary dx. I went from coding in a Hematology/Oncology clinic for 3 years to coding these hospital visits and it seems to be a different way of thinking here from what I'm used to. Looked at as it was asked, and there is no new complaint therefore with with each visit needing to stand alone-can't really pull from other previous visits so today's visit-there is no complaint from the patient, but of course they can still be sickly and need medical attention in the hospital. (??)

    Amanda, CPC
    Urology coder

  8. #8
    Ellenville, New York
    Default Hospitalists
    In situations like that, our hospitalists will document the primary dx with a notation that the patient is better, no new complaints, etc. Example might be "CC: Pnemonia, improving, no new complaints."


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

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