Wiki HPI and ROS

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jaud63

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We have a medical provider that is referring to her Assessment and Plan for the HPI and ROS rather than documenting them after the Chief Complaint. Her remark where her HPI and ROS is located on her documentation template states "see assessment and plan". Does anyone know if this is acceptable? One person within our organization was told by an AAPC member that this is fine. I personally believe this is cutting corners. Also, if this is possible is there anything in writing indicating this is an acceptable practice?

Thank you.
 
While it is certainly recommended, it is not required for the information to be under the related heading. It certainly makes coding and auditing more difficult. And each item definitely cannot be counted toward more than one element (if you count it for HPI, you cannot also count it for ROS).
Here are some links to other previous posts regarding this:
https://www.aapc.com/memberarea/forums/89284-hpi-mdm-2.html?highlight=heading
https://www.aapc.com/memberarea/forums/161920-compliance.html?highlight=heading
https://www.aapc.com/memberarea/forums/122393-coding.html?highlight=heading
https://www.aapc.com/memberarea/forums/113658-review-systems-documentation.html?highlight=heading

Unfortunately, no one has cited a specific reference that it is allowed. I suppose it may be buried in some CMS manual, but anything I found simply stated it must be documented. It did not make any mention of headings at all.

Hope this helps!
 
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You are technically allowed to refer to other portions of an encounter for information, rather than type everything all over again.

However, since the HPI and ROS are subjective, they really should be separated from the A&P, since that portion of the record is where the doctor gives their medical opinion based on the subjective + objective portion of the visit.

An encounter should be like a novel or a movie: it has a definite beginning, middle, and end. And the sections should build on each other. The provider decides what systems to exam based on the chief complaint and HPI. ("Okay, patient denies vomiting and nausea, so I don't have to look at the GI." "Patient has chest pain and edema, I need to examine the cardiovascular.") So putting the HPI at the end of the documentation is a bit like ripping out the first 1/3 of the book and shoving it in between the last few pages.
 
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