Results 1 to 10 of 10

EMR and HPI Experts...

  1. #1
    Location
    North Carolina
    Posts
    3,126
    Exclamation EMR and HPI Experts...
    Medical Coding Books
    I think we have established, in previous threads, that the chief complaint must be documented by the physician. For those of you already on an EMR system, what is your protocol for nurses/cma's taking the CC? Do you have your physician restate the CC or does your physician insert his/her name below the nurse/cma name (an indication that he has personally asked the patient and agrees with the nurse/cma's entry)?

    Our EMR system has a "audit trail"; however, if the physician doesn't somehow, somewhere, notate the CC...how can we (I) prove that we are compliant?

    I've presented this question to other auditors, educators...and we seem to agree what needs to be said and documented, but if anyone has any personal experience, I would love to hear it!
    Last edited by RebeccaWoodward*; 08-21-2008 at 07:05 PM.

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    We have EMR...when they came out to train, they told the staff that nurses could document HPI...well, I've had to re-train every single provider that THEY must personally document the HPI. If I see the nurses initials by the HPI, I won't count it. They are learning...
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    Thanks Lisa...that's what I felt might happen. The IT folks that are implementing this project agree with us. They have done their homework, too. It's going to interesting to see how this all unfolds.

    Thanks again~

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    What EMR did you purchase? We have NextGen...
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Allscripts Enterprise. Any thoughts about it?

  6. #6
    Unhappy
    Hey Lisa how is your Next Gen EMR. We have it as well but have only gotten as far as the EPM. We've had it for about a year and I think that the potential is good but there are days where I am gritting my teeth.
    adrianne, cpc

  7. #7
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Quote Originally Posted by abenson View Post
    Hey Lisa how is your Next Gen EMR. We have it as well but have only gotten as far as the EPM. We've had it for about a year and I think that the potential is good but there are days where I am gritting my teeth.
    The biggest issue I have with the EMR is that it does not guide the providers to choose 4th/5th digits for their ICD-9 coding. So the dx codes in the notes are 3 digits only...had to have that function disabled until NextGen fixes it. The docs aren't happy that they still have to use the book !! There are other issues as well, but I think people who have both the EPM and the EMR are getting along much better than we are...
    Lisa Bledsoe, CPC, CPMA

  8. #8
    Default Help!!! Urgent Care NEW vs EST.
    Our biggest concern at the moment re: Urgent Care New vs Established is does the same rules for a new and established patient apply to the urgent care setting. Or does new guidelines apply. A new patient is one who has NOT been seen by the same provider within the same specialty, within the same group in the past 3 years. I heard somwhere that Urgent care patients are Always considered new if they come in for a different problem????? I am really not sure about that! PLEASE HELP. ASAP.
    I can be reached by email at
    mammi99@hotmail.com
    or my direct number at 1-951-354-3178

    THANKS!!!!

    Marisela Amador-CPC

  9. #9
    Default
    I had this exact scenario come up just now - we have MediNotes in 2 of our practices - currently the nurses are documenting the HPI. The EMR doesn't have the option to use initials. The nurses say, "Well the physician reviews what I put, makes changes, and signs that everything is accurate and how would anyone know who did it anyway?" - and the EMR trainers also told them to do it this way.

    I realize what she is saying - but I don't feel right with it, I've explained the guidelines but I feel like it's a losing battle...How do I counter this???

  10. #10
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    That's a difficult situation, since WE all know the provider is the one that has to document the HPI... Does your EMR have an administrator that can look into the record and tell you who did what? The problem is as stated...once the provider does his/her thing, it most likely all generates with their name. Are they willing to take on the liability that what the nurse documented is completely accurate? I would make this situation known to the powers-that-be and keep it documented that you brought it up as an issue and do not agree with the situation. CYA!!
    Lisa Bledsoe, CPC, CPMA

Similar Threads

  1. GYN experts - please help
    By Missy13 in forum OB/GYN
    Replies: 1
    Last Post: 10-13-2014, 01:20 AM
  2. Need help to the experts out there
    By martha37 in forum Modifiers
    Replies: 0
    Last Post: 03-11-2010, 03:58 PM
  3. E/M experts..
    By ARCPC9491 in forum E/M
    Replies: 3
    Last Post: 03-03-2009, 03:30 PM

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.