Reducing the Burden of Clinical Documentation

QUESTION: 

What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH? Is it acceptable for my medical assistant to document the ROS, HPI and PFSH if I review the information?

ANSWER: 

Yes, as of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

“For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary and indicate in the medical record that they have done so.

CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” 

The physician must still personally perform the physical exam and medical decision-making activities

Work Smarter, Not harder...

The single most common complaint when educating physicians on proper documentation for HCCs is the amount of time it takes to document a complete ROS and HPI. Up-training medical assistants and nurses to take and document the history components can significantly reduce the time physicians spend documenting and increase the time they spend taking care of patients. 

Visit ERM365 to learn more.