My State Board of Nursing NP Documentation Guidelines

Documentation Guidelines [First Name, Last Name] [Institutional Affiliation] [Date] Documentation Guidelines My State Board of Nursing NP Documentation Guidelines emphasizes the presence or absence of documentation for seven elements as a definition of the level of Evaluation and Management (E/M) services provided. They include history, examination, medical decision-making, counseling, care coordination, nature of the problem presented, and time (DHHS, 2017). The first three are vital in determining the level of services, although the others are also essential for care coordination, counseling, and control. Additional four sub-elements also demonstrate a proper complexity level of services. They include “chief complaint (CC), history of present illness, review of systems (ROS), and past, family, and social history (PFSH)” (Bendix, 2014). Guidelines on documenting these four sub-elements direct health professionals on either including CC, ROS, and PFSH as separate elements of history or under a description of the same.  Additionally, the documentation guidelines also direct NP on the parties allowed to record and review the different elements. For example, the ancillary staff or the patient can fill a form to note ROS and PFSH. The NP is required to document all the medical issues they encounter when a patient visit the primary care setting (DHHS, 2017). These guidelines help external auditors to review the diagnoses a nurse practitioner is dealing with and influences medical decision-making. Throughout documentation for the seven elements, it is essential to note that information captured may differ for different patient populations such as children, pregnant wom...