Who can record the Chief Complaint

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Posts: 76
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Wed Jan 17, 2018 8:18 am

We are implementing a new EHR system for our office providers. They are insisting we give them something in writing that supports only the provider can document the Chief Complaint. We have asked them to change the heading to "Reason for Visit". That way, we can infer the CC from the HPI that the physician documents. They are trying to set the note up that allows the ancillary staff to do the CC and the HPI; and the doctor has a "reviewed and agree" button. We explained to them that it was not acceptable for the ancillary staff to document the HPI (it is the work of the physician or practitioner), but they do not want to change the CC to reflect that as the work of the physician also. Can anyone give me their take on if it is appropriate to allow staff to fill in the CC? First Coast, our FL Mac provider, does not opine on this. I have sent the question to them, but they take up to 45 days to respond.
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Wed Jan 17, 2018 11:06 am

In the 95 and 97 documentation guidelines, it states that ancillary staff can obtain the ROS, PFSH and vitals, and if the provider specifically references them, it can be used to support the documentation.

The explicit documentation regarding who can document the CC, has been widely addressed. When you reference the Medicare teaching guidelines, a medical student cannot even obtain it. The attending can only use the information from the MS for the ROS, PFSH and vitals, and they have to document everything else. In First coast they address the following:

The E/M documentation guidelines also furnish the following recommendations for documenting the physician’s review of PFSH and/or ROS:
• The chief complaint (CC), ROS, and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.
• An ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or when several physicians in an institutional setting or group practice use a common record. The physician’s review and update may be documented by:
• Describing any new ROS and/or PFSH information or notating there has been no change to the information
• Notating the date and location of the earlier ROS and/or PFSH
• To document that the physician reviewed the ROS and/or PFSH recorded by others (e.g., ancillary staff, a form completed by a patient), there must be a notation supplementing or confirming the information recorded by the other individuals.
They state that the CC is needed, and then specifically only call out the ROS and PFSH as able to be recorded by others. So although they

The 95 and 97 guidelines, have the same explicit comments:
Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information.

Given the fact that Medicare specifically states that ROS, PFSH and Vitals are all that a Med Student can document that a preceptor can use, and that it stats ancillary may document the ROS and PFSH, that this means that the CC can only be captured by the provider.

I am including many references to assist with this, including one from CGS that explicitly states no, to show you that it is not just presumption. This is still something that many argue on the requirements and nuances, the CC does not have to be from one portion of the record, so if ancillary staff capture it, and the provider restates it, or adds a different one, the encounter is still supported.

https://www.cms.gov/Outreach-and-Educat ... 006764.pdf
https://www.cms.gov/Outreach-and-Educat ... 006437.pdf
https://www.cms.gov/Outreach-and-Educat ... 006764.pdf
https://www.cms.gov/Outreach-and-Educat ... 006437.pdf
https://cgsmedicare.com/partb/mr/pdf/EM ... yStaff.pdf
https://www.cms.gov/Outreach-and-Educat ... 905364.pdf
https://www.cms.gov/Regulations-and-Gui ... R713PI.pdf
https://www.cms.gov/Outreach-and-Educat ... SE1419.pdf

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
Posts: 76
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Wed Jan 17, 2018 11:34 am

Thanks for your prompt response.
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