Wiki Entering HPI info physicians vs. medical assistant

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almag69

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I am reading the February 17, 2014 issue of the Part B News. In there it indicates that only a physician can enter the HPI. And that say a medical assistant can not enter it and have the physician review it. Im just curious if other offices are doing it this way and not having the ancillary staff as they put it, entering this information before the physician comes in to see the patient. Thank you for any information that can be provided.
 
That is correct. We have the MA/RN document the Chief Complaint and the Physcian/NP review and initial.(I tried to verify if the CC can be documented by MA/RN but couldn't find anything on Noridian/CMS website) But the physcian/NP does do the HPI.

The MA/RN can document the ROS and PFSH but the Physcian/NP will need to document that it was reviewed. A questionaire completed by the patient is accepteble but again, it needs to be docutmented that it was reviewed by the Physcian/NP.

Hope this helps. If anyone can verify the Chief complaint documentation - greatly apprecieated.
 
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