HPI documentation

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.

HPI documentation