Wiki Documentation by the Medical Assistant

[Colliemom]

Good morning,

We are having a discussion about what part of a physician's office note can be documented by the MA. (Specifically the CC and History) Based on current documentation guidelines, what parts of a note do you feel the MA is permitted to document?

thanks

 

[CatchTheWind]

The MA can document the entire note as long as she is only acting in the role scribe (that is, she is just writing what the provider tells her to write).

I wonder if what you really meant to ask is not "what part of the note she can document," but "what part of the visit she can perform?" CMS answers this question explicitly:

“Only the [provider] can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff…. Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice.” (See https://med.noridianmedicare.com/web/jfb/specialties/em/clarification .) “In certain instances, an office... nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician... needs to document that he or she explored the HPI in more detail.” (See https://www.aapc.com/blog/27349-confirmed-billing-provider-must-document-the-hpi .)