Every physician should own up to a patient’s history of present illness.
Ancillary staff such as registered nurses and licensed practical nurses can be handy in documenting the history for an evaluation management encounter; however not past the ROS; PFSH and important signs. From this point on, it is the doctor’s job to review and verify the authenticity of the information dispensed. To add to it, only the physician who carries out the evaluation/management service should perform and document the history of present illness.
For instance: A patient shows up in the office with early signs of pneumonia (480-486). The nurse notes down ‘cold and high fever for the last three days’ and takes the patient’s ROS, PFSH, and vital signs. When the patient sits down with the pulmonologist, the physician carries out the HPI and expands on what the nurse has noted. In order to rule out pneumonia, he rules out pneumonia.
If you don’t heed to this important guideline, you could be risking a denial.
Bear in mind, the doctor should always treat any information documented by the ancillary staff as ‘initial information’ and support the reported visit level with an official entry, documenting his own PHI.
But then this general rule remains: HPI, medical decision making and examination are considered physician’s work and not relegated to ancillary staff.
A scribe may do the doctor’s work – well sort of
In some instances, a physician would ask his ancillary staff to act as ‘scribe’ documenting the information as the doctor dictates it. Most payers allow providers to use scribes but only to help in documenting the services performed by the physician.
Here’s a CMS definition of scribe: “A scribe is one who follows the doctor around and writes word for word, what the doctor says as he is examining the patient — a sort of human tape recorder.”
Aside from nurses, medical students, physician assistants or front desk staff could all act as a scribe.
Must do: The physician should assess the scribe’s documentation and then sign and date the note to supplement or confirm the information recorded by others. The scribe should also be identified in the medical records with the proper attestation and signature.
And what about EMRs?
Practices using electronic medical records in their office recommend that the provider type the note or use customizable “auto-fills” to drop in commonly used notes while in the room. For doctors who do not wish to be disturbed with this work, they may use the following choices:
Have a scribe fill out the EMR in the room.
Have a member of staff type your paper notes into the EMR after the visit.
“Copy-paste” text received in a Word file from a transcription service into the EMR. Whether your practice is into EMRs or good old written medical records, you should remember that a scribe acts as a ‘shadow’ to the doctor. She records all of the chart elements that you – coders – look for in deciding evaluation/management levels and CPTs. The scribing activity too must be noted in the encounter note. Scribe guidelines emphasize that scribes are recording these elements strictly from physician direction. Just like medical coders, scribes can’t assume that something was done minus clear direction from the physician. For more on this and for other specialty-specific articles to assist your pulmonology coding, sign up for a good medical coding resource like Coding Institute.