Summary: Advanced Practice Registered Nurses

Issues and Trends
As advanced practice registered nurses (APRNs), it is vital that one must know how to properly document in electronic records. Concise documentation is deemed necessary for two reasons: 1) to provide adequate quality of care for patients, and 2) to receive prompt payments on furnished services (Centers for Medicare and Medicaid [CMS], 2014). If information is not documented, then you typically will not get paid for it. Furthermore, recording the patient’s story, objective findings, assessment, and treatment plan for the patient all serve as a legal record for the future (Phillips, 2013). This paper will discuss the purpose of evaluation and management (E/M) codes, while summarizing three components of E/M documentation
In conjunction with International Classification of Diseases (ICD), CPT codes function as an important set of codes for health care providers to become familiar with (MBAC, 2016). Physicians and other health care providers are able to bill patients for all services performed at that visit. Another prominent reason for E/M services is the ability for government agencies to track important health data for efficiency and performance (MBAC,
The CC is a concise statement that describes the principal reason for the patient’s visit (Gurland, 2015). The physician records the CC in the patient’s own words, and the patient’s medical record should replicate the CC (CMS, 2014). The HPI is developed around the CC and is considered to be a description of the patient’s current ailment beginning with the initial symptoms of illness (CMS, 2014). The five elements that compose the HPI are location, quality, severity, duration, timing, context, alleviating or aggravating factors, and related signs and symptoms (CMS, 2014). Brief and extended are classified as the two types of HPIs. A brief HPI incorporates one to three elements of the HPI, while an extended HPI includes at least four components of the illness or an updated status of three chronic conditions (Miller, 2012). The ROS is collected by asking the patient various questions regarding signs and symptoms experienced in other body systems (Miller, 2012). The ROS is composed of three levels: problem pertinent, extended, and complete (Miller, 2012). The PFSH is also an important part of the history and includes all surgeries, injuries, illnesses, past and current social activities, and a review of family medical events that places the patient at risk in the future (CMS, 2014).