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?