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Chief Complaint

Melissa Posted Mon 20th of January, 2020 17:21:30 PM
Hello, I have a dictation from a Cardiology practice where the nursing staff has documented a CC as Chest Pain. However, in the "additional complaints" section, the provider indicates the patient is there for follow up but is not having any cardiac complaints at this time" In the provider's HPI, he states "the patient is here for follow -up appointment and denies any chest pain or sob, says she is doing well" The review of systems concurs with his HPI note. Does this note have to have an addendum to the chief complaint or is the rest of the dictation sufficient to infer the correct chief complaint?
SuperCoder Answered Tue 21st of January, 2020 03:35:41 AM

Hello Melissa,

Thank you for your question.

 

The rest of the dictation is sufficient to infer the correct chief complaint; since, the Evaluation and Management was provided by the provider, not by the nurse. HPI was documented by the performing provider, therefore, the nurse’s notes do not count.

 

Also, the addendum is not required, Since, the Evaluation and Management Service(s) was performed by the provider only.

 

Hope that helps!

Thanks

Melissa Posted Tue 21st of January, 2020 08:37:38 AM
Thank you
SuperCoder Answered Wed 22nd of January, 2020 00:15:15 AM

Thank you, happy to help.

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