Wiki HPI Question----HELP

[despinoza]

So I have a provider that is argumentative about HPI.... I know that ultimately the provider or NP is responsible for the HPI. Now with that being said for auditing purposes.

Can the MA retrieve the information and then he signs off on it stating he agrees and documents..


On paper charts can they MA fill out the HPI portion but the Provider signs the paper taking full responsibility for the chart .

Is that vaild? or does it all need to be in his handwriting and under his name for EMR?

Im so confused. Please help

What is the correct documentation for both EMR and paper charts for auditing purposes on HPI

 

[thomas7331]

Auditing the EMR is a little easier because there's usually an audit trail that shows who actually entered the information (EMR tech support should be able to provide that, if it's not immediately apparent) which is harder to tell in a paper chart. If someone other than the provider is entering that information into the chart, i.e. acting as a scribe, providers are usually advised to include a statement certifying that this person was just acting as scribe and not performing the actual elements of the service. That's a tough question - it's not always easy to tell who's doing what in some medical record formats.

 

[ndanh01]

Hpi

Hello Despinoza,

The answer is no. Here you go! From Noridian's website, I am hoping this answers your question regarding the HPI.

Link: https://med.noridianmedicare.com/web/jfb/education/event-materials/em-qa

Evaluation and Management Clarification

Per CMS, only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff.
Noridian Healthcare Solutions (Noridaian) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.
Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be "I have reviewed the HPI and agree with above."