Documenting HPI and CC

I am a COT in a retina practice and we are currently using EMR (not an accredited one yet, one of our Drs created it). I would like to know who needs to document the CC and HPI and where I can find that information in writing to bring to my Drs attention.

HPI and CC

The HPI must be documented by the MD.

Take a look at this article:

http://codapedia.com/-article_118_.cfm

It's written by Todd Thomas, and I think covers the issues really well.