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I do coding for inpt consult and initial hosp visits. My attendings are under the impression that they should get credit for a comatose or intubated pt if the ROS are not done. How should ROS be documented in this case?
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Wiki Correct ROS documentation
pattonutvols
New
Ros
Unable to obtain ROS due to patient being comatose or other condition should be described that keeps them from being able to obtain.
Unable to obtain ROS due to patient being comatose or other condition should be described that keeps them from being able to obtain.
Melody Irvine
Networker
If they are unable to obtain history due to the patient's medical condition, it should be documented why they are unable to obtain this information and given full credit for it. Example: dementia, comatose
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Thank you Melody and Patton
Kris78
Networker
Comprehensive
I agree. I believe the guidelines state that if you describe why you cannot obtain a ROS from patient or family member due to patient being intubated or comatose , then the HX portion is Comprehensive.
I agree. I believe the guidelines state that if you describe why you cannot obtain a ROS from patient or family member due to patient being intubated or comatose , then the HX portion is Comprehensive.