Wiki Aduting with 1995 guidelines

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AR2728

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I frequently use the 1997 guidelines, but am now finding some of our specialists may benefit using the 1995 guidelines. I find them to be more confusing and I am struggling. I would appreciate any feedback on the following exam audited using 1995 guidelines.

PHYSICAL EXAMINATION: When he came to the emergency room documented heart rate of 77. The patient was saturating at 87% to 91% on 2 liters nasal cannula. His blood pressure was 139/65. His telemetry strip read basically atrial flutter but a 2:1 or 3:1 block with diffuse P wave inversion which is secondary to the atrial flutter pattern. The patient's temperature was also 101.3. He was lying in bed comfortably. He was alert. He was not oriented to place.
CARDIAC EXAM: Showed regular rate and rhythm. S1, S2 were heard. Heart sounds were
distant. No obvious murmurs, rubs or gallops were noted.
LUNGS: Examination of the lungs posteriorly revealed bibasilar rales. The upper lung zones were clear to auscultation posteriorly.
ABDOMEN: Soft. Non-tender. Non-distended. Positive bowel sounds throughout. No rebound, rigidity, or guarding were noted.
EXTREMITIES: The lower extremities revealed +2 pitting edema.

One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?

Thanks for the assistance.
 
One additional question: The physician states for ROS: unobtainable as patient does not give a proper history. So, he has nothing for ROS--correct?
Click to expand...

I don't think 95 or 97 makes a difference in the ROS.

If the physician documents the patients medical condition that makes it impossible to obtain or documents the attempts / problems encoutered when trying to get the ROS, they can take the complete. I don't think what you have is enough to do that. So if that is all the info you have, I would say this was nothing for ROS.
 
The additional details of the note-regarding the ROS Unobtainable are as follows:

Unable to give proper history when I asked him if he has had any fever. He says "no" and he essentially say "no" for every question that I ask him. He has advances ALZ/Dementia and does not know he is in the hospital.
 
Caveat

The additional note documenting the advanced dementia should be enough to apply the acuity caveat to the ROS. But it woukld help if the physician stated that due to dementia/alz. history could not be obtained.

Jim
 
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