Wiki Exam Deferred by Patient

[chasarmil]

Can we count an exam being done if the doctor writes that the exam was deferred by the patient?
My physician states yes, as long as you document each area that the exam was deferred by the patient.

Thanks
Robin

 

[mitchellde]

no you cannot count as hands on that which was not, exam is hands on assessment. History can be counted if it is documented that the patient is incapable of answering question such as unconscious or mental disability.