Wiki HPI documentation

[cheryldudley8]

Good Morning,

I know the HPI has to be documented by the rendering provider, however I have a few questions in regards to the actual, technical documentation taken by the provider or other staff versus the documentation of the provider reviewing/reaching an agreement of an HPI documented by ancillary staff?

Coming from an Urgent care coding perspective, most of our patients are new. With this, it is imperative that the history be documented correctly. Also, many providers tend to document ( or lack thereof ) very differently when it comes to the HPI. So I would greatly appreciate others opinions on this matter.

Does this count as a documented HPI by provider and therefore counts as elements towards either a brief or extended HPI or not??

1. HPI elements technically documented by ancillary staff and then at bottom of the HPI encounter note, there is a note either stating " MD note" or the name of the provider Note/stamp etc and then states agree with and/or review and agree with above statement (referring to all HPI elements documented by other staff)??

2. Or, all HPI documented by ancillary staff, and then when I run the audit report to see who documented what, it proves ancillary staff documented all HPI but like with all the other sections of the encounter note with our software, the provider can mark it off as reviewed. And the only thing done by the provider in regards to HPI, is they have marked it off as reviewed on the audit trail????

Does the HPI technically have to be documented by provider or does a statement stating it was reviewed etc by the provider justify or give credit to the provider for the HPI elements?

Any information would be greatly appreciated. Thanks again in advance.

 

[kak6]

this kind of sounds like a scribe documenting for MD which is fine as long as the scribe name, who they are scribing for is included in the record. also the MD needs to state they reviewed and agree or made revisions to documentation and sign and I sounds like that is being done correctly. Maybe you would feel better about it if the ancillary staff included their name and MD acknowledged.

 

[CatchTheWind]

Documentation by a scribe means that the assistant is writing down what the provider is saying. If the assistant is obtaining the HPI from the patient, and writing it, this is not a scribe situation.

According to an article published by Palmetto GBA (the Medicare contractor for the Carolinas and Virginias), ancillary staff may only obtain and document the vital signs, ROS, and PFSH, and even these "must be reviewed by the [provider] who must write a statement that it is reviewed and correct or add to it."

As for the HPI: "Only the physician or NPP that is conducting the E/M service can perform the... HPI. This is considered physician work and not relegated to ancillary staff.... In certain instances, a... nurse may document pertinent information ... but... the physician providing this E/M service... needs to document that he or she explored the HPI in more detail." http://www.palmettogba.com/palmetto...Center~Weekly Tips~94MHC73301?open&navmenu=||


Palmetto GBA has a great publication of simple E/M tips at http://www.palmettogba.com/palmetto...sdiction 11 Part B~EM Help Center~Weekly Tips . Even those who are not in their jurisdiction can learn a lot from them.

 

[jdibble]

Good Morning,

I know the HPI has to be documented by the rendering provider, however I have a few questions in regards to the actual, technical documentation taken by the provider or other staff versus the documentation of the provider reviewing/reaching an agreement of an HPI documented by ancillary staff?

Coming from an Urgent care coding perspective, most of our patients are new. With this, it is imperative that the history be documented correctly. Also, many providers tend to document ( or lack thereof ) very differently when it comes to the HPI. So I would greatly appreciate others opinions on this matter.

Does this count as a documented HPI by provider and therefore counts as elements towards either a brief or extended HPI or not??

1. HPI elements technically documented by ancillary staff and then at bottom of the HPI encounter note, there is a note either stating " MD note" or the name of the provider Note/stamp etc and then states agree with and/or review and agree with above statement (referring to all HPI elements documented by other staff)??

2. Or, all HPI documented by ancillary staff, and then when I run the audit report to see who documented what, it proves ancillary staff documented all HPI but like with all the other sections of the encounter note with our software, the provider can mark it off as reviewed. And the only thing done by the provider in regards to HPI, is they have marked it off as reviewed on the audit trail????

Does the HPI technically have to be documented by provider or does a statement stating it was reviewed etc by the provider justify or give credit to the provider for the HPI elements?

Any information would be greatly appreciated. Thanks again in advance.

The documentation of the HPI must be done by the Physician and no one else. They cannot sign off on someone else's documentation. I did the coding and billing for an Urgent Care for over 9 years and I had the same issue with the original template that was used for the visits. (handwritten - not EMR). I had to educate the physicians to write the HPI themselves and to disregard the little check box that stated they reviewed the nurse's note. It didn't matter if they basically repeated the nurse note - as long as it was in their handwritting I could use it!!! We finally changed that issue with a new template!

Hope that helps!