Wiki Chief Complaint

[AZ_coder]

Hello;
Our office staff utilizes MAs to document the chief complaints from the patient. (The documentation is properly signed by the MA.) It has come into question as to how we can use this information.

Typically, the chief complaint is used to support HPI portion of the E&M. Some staff believe the information can be used to support the Exam or the ROS.

Does this seem appropriate? I'm not sure since the information is obtained by the MA not the provider and the provider does not specifically reference the chief complaint anywhere in his/her documentation.

Thank you!!

 

[jackson7591]

Previous

I think there is a detailed post regarding this issue elsewhere on this site. I googled documentation requirements for chief complaint and get sent to a series of posts from several years ago?

It was posted by uksjmartin. 4-15-09

 

[penny48]

BrandieC,

You are correct the CC can only support the HPI, otherwise it is considered double dipping for auditing purposes.