Wiki Help with Meaningful Use documentation!!!

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mgord

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I have a provider that wants his nurses to document the counseling for tobacco cessation and BMI management when they are recording vitals and PMSF history. Because 1. this is documented before it's even being done and 2. this is recorded under Preventive Medicine in the Assessment, I felt like this was part of the Medical Decision Making.
I also know that ancillary staff should only document ROS, PMFS history and vitals. However Cahaba does not state this clearly anywhere that I can see and I know this particular provider would push the issue.

Can anyone please help me with this? Am I wrong; should the nurses be able to document this? And can anyone point me in the direction where I can find some actual documentation to present to support my stance on this?
Thanks for any help you may have!!
MBH
 
For meaningful use the nurses are allowed to document the following: smoking status, vitals, med allergies, problem list, and current meds. Check out CMS website, they have many articles on Meaningful Use and incident-to.
 
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