mardi 28 avril 2015

HPI Documentation


I just started working as a practice manager for a solo practice specialist who refuses to listen to me. He is making his staff do all chart documentation at intake including doing the HPI for him! Even going so far as to have them select the bullets in the templates for location, severity, timing, etc. I have shown him in black and white the CMS guidelines stating that ancillary staff cannot perform or document the HPI, the physician himself must do this. This is a huge problem for me. His response was do it my way or quit. I guess my question is, has something changed and is ancillary staff now allowed to perform and document the HPI or am I correct and we are headed for huge problems down the road if an audit is to occur? If anyone has any information (more current) either way, I would appreciate it. We have an EMR and I tried to explain that everything is documented as to who performs each action and it is even time stamped. His answer was again, do it my way or quit. That, right now, is not an option.



HPI Documentation

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