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avon4117

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If a consult was done in the hospital (pt was admitted) and ros could not be performed because pt is in a lot of pain.Dr did document. Can any ROS be counted? If not then do I default to a medical care day?
 
Caveat

If the provider documented the reason they couldn't complete the history then it would fall under caveat. "A lot of pain" is somewhat subjective, but if the physician documented this is the reason and no family etc was available to help with history then you are OK. Hey you do have one ROS element with "Lot of pain" unless used for HPI!

Jim
 
If a provider states why they can't complete a ROS or obtain PFSH you can give them full credit for both. So they would receive a comprehensive ROS and comprehensive history. A good example is patient has dementia and is poor historian or patient was unconscious.
 
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