Forum - Questions & Answers

Sep 24th, 2010 - KINGRR 2 

Documentation of chief complaint?

Some of our providers use templates where the nurse documents the chief complaint, PFSH, and sometimes ROS. The provider documents the HPI and/or ROS (sometimes no HPI and/or ROS is documented) and signs off to reviewing ancillary staff documentation. From an audit standpoint... can the Chief Complaint be documented by only ancillary staff?


Sep 24th, 2010 -

No

anyone can document the Chief Complaint, only the provider can document the HPI. Is there really no HPI on some charts?



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