tci General Surgery Coding Alert - 2005 Issue 10

Reader Questions: Nonphysician Staff Can Perform History Element

Question: Must the surgeon take a patient's history, or can a nurse or other nonphysician staff take the history prior to the surgeon meeting the patient?California SubscriberAnswer: Any employee can take the history. In fact, the E/M service documentation guidelines state that ancillary staff may record the review of systems (ROS) and/or past family social history (PFSH). Although nurses often record this information, a front-desk staff member may even perform the function. The surgeon or nurse practitioner, however, must complete the history of present illness (HPI).Be careful: The physician must sign off on the patient's chart and...

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