Wiki Alert & Oriented

[SUEV]

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

 

[FTessaBartels]

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

 

[SUEV]

Yes, it does help. Thanks!