Would this count as having any validity being that the information was obtained by ancillary staff initially? Shouldn’t there be a notation at least to state that he/she reviewed it for accuracy and that he/she performed it and adding to it if necessary?
Is there anything from CMS aside from the Noridian link (https://med.noridianmedicare.com/web…/clarification) which has more clarification? There is argument that this mainly pertains to HPI and that it is only the HPI that should have a notation for reviewed for accuracy, did perform it and adding to it if necessary. Does this also apply to Chief Complaint?
Can I advise my provider that carrying forward the Chief Complaint is not recommended without notation or he should be documenting the chief complaint himself?