Hi,
I've been directed that if a provider gives the statement in their dictation "patient is Alert & Oriented x3 and in no acute distress", w/ 1997 guidelines 3 bullets would be credited:
Alert = Psych; Mood & Affect (I don't agree)
Oriented x3 = Psych; Orientation to time, place, and person (I agree)
no acute distress = Const; general appearance (I agree)
I have no problem w/ the Orientation credit and the General Appearance credit either. But to give credit in Psych - Mood and Affect for "Alert" doesn't make sense to me nor to many of my providers. I've research Pink Sheets and the internet w/o any direction other than "Alert & Oriented x3" means pt is Oriented to time, place, and person. Thus, I feel that statement should only get the orientation bullet.
Does anyone have any insight or materials, websites, and/or guidelines w/ more direction
?
I've been directed that if a provider gives the statement in their dictation "patient is Alert & Oriented x3 and in no acute distress", w/ 1997 guidelines 3 bullets would be credited:
Alert = Psych; Mood & Affect (I don't agree)
Oriented x3 = Psych; Orientation to time, place, and person (I agree)
no acute distress = Const; general appearance (I agree)
I have no problem w/ the Orientation credit and the General Appearance credit either. But to give credit in Psych - Mood and Affect for "Alert" doesn't make sense to me nor to many of my providers. I've research Pink Sheets and the internet w/o any direction other than "Alert & Oriented x3" means pt is Oriented to time, place, and person. Thus, I feel that statement should only get the orientation bullet.
Does anyone have any insight or materials, websites, and/or guidelines w/ more direction
?