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Help GCS code in triage?

Thread starter pamc
Start date Wednesday at 10:04 AM

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pamc

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Wednesday at 10:04 AM

My office has a difference of opinion, one of our auditors wants the coders to pick op the GCS when entered in the ER nurse triage documentation, it is not entered in the doctors notes nor does the doctor bring it into his note. The doctor does not reference it at all. Triage is a snapshot of the patients urgency for care. The providers assessment is definitive for the patients encounter visit. The GSC scale is a clinical data point, not a diagnosis in itself. Please weigh in.

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