Ensure Your Nurse's Notes Are Utilized

By Author: Leesa Israel
Total Articles: 4
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Your physician is supposed to review and sign any nurse's HPI notes.

In these times of economic downturn, your practice is possible doing all it can to maximize physician and staff time. But if you're allowing your nurses capture the patient's history of present illness (HPI), you're inviting an audit and finally extra cost.

You should not let your nurses perform the doctor's duty, or you could end up with a non-payable visit. Here are the medical billing expert pointers on when you can take advantage of your nurses' time without inviting challenges for your practice.

Remember, the only parts of the E/M visit that an RN can document on her own are the review of systems (ROS) which include past, family, and social history (PFSH); and vital signs. The physician or mid-level provider must assess those three parts and then write a statement that the nurse's documentation is right or add to it.

Either the physician or non-physician practitioner who conducts the E/M service can perform the history of present illness (HPI).

Exception: In few cases, it ...
... is acceptable if an office or Emergency Department triage nurse documents "relevant information" regarding the chief complaint (CC) or HPI. But you should view those notes as "preliminary information." The doctor giving the E/M service is supposed to document that he or she reviewed the HPI in more detail.

Use Scribes for Documentation Purposes Only

In several practices, the physician often dictates his findings to a non-physician provider who performs as a "scribe," documenting the information according to the physician. Medicare payers also have certain rules for this type of arrangement.

When using a scribe, it's significant to remember that the scribe cannot exclaim any personal observations. The scribe is only documenting the services carried out by the physician and observed by the scribe.

Moreover, the physician is essentially required to review the scribe's documentation, and then sign the note showing that it has been reviewed by him and he/she is in agreement.

Get to Know Signature Requirements

CMS has updated its signature requirements last year, citing the rules that you must follow in order to meet Medicare's documentation requirements. CMS maintains that in order to be valid for Medicare medical review purposes. It is important that an attestation statement is signed and be dated by the author of the medical record entry and should essentially contain adequate information to identify the beneficiary.

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