The chief complaint (CC) or history of present illness (HPI) usually satisfies or addresses this requirement. Why then, in so many notes, do physicians fail to document the true purpose of patient encounters? Providers often jot down phrases or comments in an attempt to explain patient visits, but such notation actually falls far short of what's required for an accurate read of why a patient was treated.
How many notes begin with a CC that reads: "Here for flu," "Here for labs," "Here for follow-up of chronic medical problems," "Here for refills," or simply, "Labs"? Do these conventions or shorthand methods of dealing with the required CC/HPI fill the bill? No.
One explanation is that this first part of a patient's note is often completed by a nurse or a medical assistant who is asked to provide some type of context for the visit, and that person is permitted to use these shorthand conventions. Whether a physician or support staff member completes this part of a note, such shorthand conventions are typically used because no one wants to laboriously document the elements of chronic disease follow-up visits with potentially several dozen patients, day after day, month after month.
Most providers are unaware that for these types of visits - extremely common within the Medicare population - it is the status of the chronic illness as compared with the patient's last visit that dictates a patient's CC and HPI. In 1997, the government's documentation guideline section for recording a patient's HPI was expanded to include the status of chronic illness as opposed to the "where, what, how, and how bad" that traditionally informs a patient's HPI. A clear statement regarding the status of an existing illness should replace tangential comments such as "Labs."
When you treat patients with chronic illnesses on an ongoing basis, you should begin notes with a summary list that mirrors the assessment and plan (A/P) at the end of the note. Label and number each problem addressed, and provide a quick status of each. For example, such a note may read, "HTN well controlled, no side effects, blood pressures running in the 130s." If you clearly indicate each problem you handle during a visit, you effectively create an outline of the encounter that will leave no room for confusion.
Careful documentation is vitally important to payers. If you don't make clear from the outset the number and nature of the problems addressed during a patient visit, you run the risk of recording notes in which the HPI area looks quite different from the A/P area.
I've often looked at the A/P section of a patient's note and seen problems listed that do not appear in the HPI section. In such cases, it's reasonable to wonder, "Where did these problems come from?" Payers will likewise wonder whether problems that "appear" in this fashion were actually part of the visit.
To clarify which services you provide during each patient visit, provide that patient's history - not an abbreviation of it. As far as I can tell, if you abbreviate a note, your payer may very well respond by abbreviating your payment.
Bill Dacey, MHA/MBA, CPC is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for over 18 years. He can be reached at firstname.lastname@example.org or via email@example.com.
This article originally appeared in the November/December 2006 issue of Physicians Practice.