In my office the nurse does the c/c and HPI and I do everything else. I use a template I made for my standard ROS and I do my best to actually go through it with each patient. Most of my regular patients thinks it is funny but lets face it, it is fraud and abuse to bill medicare for an intermediate visit without doing it. I do remember one patient had no respiratory complaints, just felt sick, but had physical finding and a positive CXR for pneumonia, so it can happen. I also have a template for my standard complete physical and one for what I call a short physical. If what I actually do strays too far from one of those I type it in from scratch.
I got a letter from Humana a couple of days ago expecting everyone under 20 should have a growth chart. All the payers expect a full set of vital signs so I expect my nurse to do one on every patient.
BTW, dictation isn't perfect. Did you catch this the other day? "Transcription software is tied to substantial error rate"
http://univadis.com/player/yihzkepe...hebgu&ts=2018071600&o=tile_01_idI routinely get 10 plus page records from the big local hospital network where the patient tells me the doctor didn't spend 60 seconds with them or lay a finger on them. It is obvious that their system is geared for reimbursement.
