Questions and Answer

Question: Our CMA's perform the ROS under the EHR. As the Provider does the HPI, we add pertinent and detailed information. One of the CRNP's argues that we need to correct the ROS if the HPI reveals different information. She feels the Provider is responsible for the information and we should correct it. Our physician says that the billing company feels we shouldn't change it as it is changing information put in by someone else. What is the correct process?

Answer Here is my opinion: The progress note reflects the most accurate information according to the provider who signs it. Sometimes if you have a nurse or student that starts or writes a note, you will change it if some of the information is incorrect. Now you have to keep in mind the difference between History (subjective) and Exam (objective) findings. Sometimes you will have history that may be incorrect; it is okay to document it because it is not your findings, rather it is what has been told to you.

If your HPI and ROS are different, all you have to do is figure out a way to make sure the note makes sense in whatever way they differ. Or correct it. For example, if I have a new patient and they fill out the ROS section and mark negative on all the things under the allergy section, then tell me about their allergy symptoms in History, I can handle it one of a few ways.

What I will typically do is scan in their ROS form into our EMR to show that the ROS is what the patient answered. Usually though I will have a ROS section and instead of writing "Allergic: Negative" I will write the more accurate description based on the questions they answered on my new patient forms: "Allergic: Denies hay fever/itchy eyes." Then your history is consistent with what you found and also lets the patient answer the way they want to.

As an aside I have to admit that I haven't looked at my new patient paperwork in 10 years. I'm going to change that question. Who really says 'hay fever' anyways?