Wiki Credit for this?

Is this an EMR or did they actually dictate this?

I would give credit for a psych ROS but I would probably point this out to the provider.

Just my take on it

Laura, CPC
 
Is this information obtained by asking the patient? Is this something that was previously recorded? Perhaps the patient is seen for the dementia and this reflects the chief complaint rather than the ROS. If this statement is the result of someone asking the patient that would support ROS, otherwise I would judge the statement within the context of the note. It could also be past history or maybe chief complaint/HPI....
 
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