# Who can document the HPI in the Electronic Health Record?



## Pam Brooks (Dec 5, 2011)

Other than this (in the CMS's E&M Services Guide, below)does anyone have regulatory guidance that points to whether or not ancillary staff may record HPI information in an EHR? Our physicians are thinking (with some mis-guided support from our EHR vendor) that this would be a big time-saver. I say that a physician must document his own HPI,but cannot find anything that comes right out and says that. We use NextGen's EHR (version 7.8). Anyone have supporting documentation (no opinions, please....I have a hundred of those!)  in regards to documentation of history by a physican or qualified NPP only?? Thanks in advance! 

*Notes on the Documentation of History *
❖ [FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Describing any new ROS and/or PFSH information or noting there has been no change in the information; and [/FONT]
[/FONT][/FONT][FONT=Courier New,Courier New][FONT=Courier New,Courier New][FONT=Courier New,Courier New]• [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]Noting the date and location of the earlier ROS and/or PFSH. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]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. [/FONT]
[/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]❖ [/FONT][/FONT][/FONT][FONT=Arial,Arial][FONT=Arial,Arial][FONT=Arial,Arial]If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history. [/FONT]
[/FONT][/FONT]


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## RebeccaWoodward* (Dec 5, 2011)

Pam,

I know this is my Medicare carrier but maybe this will help?

Jurisdiction 11 Part B 
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. *The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

Scribe (E/M Services):
If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed and sign his/her name. The name of the scribe must be identified in the medical records.

Ancillary staff does not need to be employed by the physician (example - hospital employees).

Resources: 

CMS 1995 & 1997 E/M Guidelines 



last updated on 10/04/2011

http://www.palmettogba.com/palmetto...Asked Questions~EM~8EELQE6434?open&navmenu=||


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## Pam Brooks (Dec 5, 2011)

Thanks, Rebecca.  Our contractor, NHIC has not come out with any such clarification, that I am aware of.  And our provider rep just quit.......ugh!!!


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## alasley (Jan 26, 2012)

Pam - I found the following information from our contractor, WPS. Below is a snippet.

Either the ancillary staff or the patient may complete the Review of Systems (ROS) and the Past Family Social History (PFSH) as part of the template, checklist, and/or electronic medical record. The provider must notate his/her review of the information. Additions to the file or confirming notations substantiate the provider's review. 

The provider may use an ROS or PFSH from a previous encounter. The provider must notate the date of the earlier ROS or PFSH and review all elements of the previous encounter notating any changes or elements not reviewed. 

The billing provider must perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation.

http://www.wpsmedicare.com/part_b/resources/provider_types/em_checklist.shtml

I also found some information on Scribes...

http://www.wpsmedicare.com/part_b/departments/medical_review/2009_1221_scribes.shtml


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## cheermom68 (Jan 27, 2012)

*Hpi*

That is a popular mis-statement by vendors.  
The providers aren't happy when we tell them that they cannot allow their nurses to document the HPI.  

LeeAnn


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## cansas (Feb 28, 2012)

Below is the AAOS take on CC and HPI documentation:  

http://www.aaos.org/news/bulletin/oct07/managing8.asp

On Pg 5 of the 1995 guidelines state that ROS and PFSH can be documented by staff.  It doesn't say that about any other section.  If it isn't documented that we can, we don't.


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## elleyl (Feb 29, 2012)

*Hpi*

Pam,  

Our JMac carrier is WPS and in two different areas on their website they state only the physician can perform 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.

Q 21. If the nurse takes the HPI, can the physician then state, "HPI as above by the nurse" or just "HPI as above in the documentation"? 
A 21. No. The physician billing the service must document the HPI. 

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml


Correct Use of Checklists in Evaluation and Management (E/M) Documentation
Physicians and non-physician practitioners, referred to below as "provider," may use templates, checklists, and/or electronic medical records to assist in documenting services and saving time. Medicare considers these as acceptable documentation. However, the documentation submitted must be specific to the patient and the service in question.
Here are some things to keep in mind when using templates, checklists, and/or electronic medical records. 
•	Either the ancillary staff or the patient may complete the Review of Systems (ROS) and the Past Family Social History (PFSH) as part of the template, checklist, and/or electronic medical record. The provider must notate his/her review of the information. Additions to the file or confirming notations substantiate the provider's review. 
•	The provider may use an ROS or PFSH from a previous encounter. The provider must notate the date of the earlier ROS or PFSH and review all elements of the previous encounter notating any changes or elements not reviewed. 
•	The billing provider must perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation. 

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/em_checklist.shtml


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## Pam Brooks (Mar 1, 2012)

Thanks, Linda.  I did see the WPS guidelines; I can only wish that NHIC was as forthright with information.  They even contradict themselves on their website....drives us crazy.  

Ah, well, nobody ever told me this was going to be easy!


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## rthames052006 (Mar 1, 2012)

RebeccaWoodward* said:


> Pam,
> 
> I know this is my Medicare carrier but maybe this will help?
> 
> ...



Rebecca:

Sounds like my MAC carrier guidelines as well. Thanks for sharing!


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## RebeccaWoodward* (Mar 1, 2012)

Anytime!  Hope you're doing well!


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## toriesurf (Oct 5, 2015)

Rebecca, quick question as one of my providers are asking. Can a patient answer an HPI type of worksheet and the physician looks it over, adds more info if needed then scan it to the pt's ehr file? She wants to do this then put "refer to attached" as her HPI section. Based on my knowledge this does not make sense as the provider should be asking the HPI questions to help guide the visit but I don't know the compliance with attaching a document for the HPI.... Can you help with this? It's an interesting question. 
thanks!


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