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Wiki Alert & Oriented

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SUEV

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If a provider documents that a patient is "alert and oriented in no acute distress", does this count as a psych exam? I thought I had seen somewhere that it should be alert & oriented x3 but I can't find the source material.
Thanks,
Sue
 
Constitutional

Unless the physician specifies "alert & oriented x 3" I do not count this as psych, just part of describing the general appearance, which falls under constitutional.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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