tci ED Coding & Reimbursement Alert - 2000 Issue 4

Reader Question: Documentation of the History of Present Illness

Question: I would like some written information about the documentation of the history of present illness (HPI) portion of the patients medical history on pre-printed forms. It is my understanding the review of systems (ROS) and the past, family, social history (PFSH) can be documented by nursing/ancillary staff for the physician and that this documentation will stand with HCFA as long as the physicians signature is on the form stating that he has reviewed the nursing assessment. It is also my understanding that the ER physician must complete his own HPI. The HPI is essentially the same information that...

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