Wiki Hospital E&M Documentation

[OliviaPrice]

I posted this once before...but I'm needing more clarification than what was provided on the first post...

I'm needing to know if this is appropriate:

We have RN's that assist our physician's in the hospital with their rounding. The RN will go in to visit with the patient and obtain a "Pre-assessment" of the patient (the intent here is to identify any emergent cases for the physician). The RN will perform a full HPI, ROS, PFSH, exam and an initial assessment. The RN will document all this information into the EMR and hold the note.

The physician will then present bedside to the patient and perform his/her own HPI, exam and assessment. The physician will take the note the RN documented, make his/her additions/deletions/revisions and electronically sign the note.

Both the RN & physician's electronic signature will appear on the report with a date & time stamp.

My question.....
1) Is this documentation acceptable for the physician to bill his level of service considering the original information was obtained and documented by the RN (keep in mind that the physician does perform all aspects of the documentation)?

2) Would it be of any concern or benefit if the physician added a statement of "I personally examined and interviewed the patient and agree with the exam and note." at the bottom of the note?

 

[mitchellde]

only the provider documentation of the HPI exam and assessment can count. The RN is not an NP and therefore not considered qualified to render this type of service. The RN can obtain the ROS but the provider must review this with the patient and note the positive issues and any pertinent negatives. The provider must document everything in his/her own words so to speak , it cannot be performed by ancillary staff. If this were an NP then it would be allowable as an NP is a qualified medical personnel to perform this service and the visit would be considered a shared encounter.

 

[cheermom68]

I agree with Debra, only the documentation personally performed by the MD, other than the ROS, PFSH, vitals, can be counted toward the level. The statement "I personally ......" is not sufficient for billing purposes. It is outside an RN scope of practice to perform the exam and assessment.
RN's can perform a nursing clinical exam and assessment, but this is not equivalent to the exam and assessment required for billing and patient care purposes.