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Wiki History unobtainable

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kjstearns

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Is it acceptable to assume that PFSH & ROS are also unobtainable if the physician writes in their HPI "history unobtainable due to patient being intoxicated"? Or do they need to specifically say "past social history unobtainable due to XXXX, past family history unobtainable due to XXX, ROS unobtainable due to XXX"?

Thanks in advance,
Kirsten, CPC
 
kjstearns said:
Is it acceptable to assume that PFSH & ROS are also unobtainable if the physician writes in their HPI "history unobtainable due to patient being intoxicated"? Or do they need to specifically say "past social history unobtainable due to XXXX, past family history unobtainable due to XXX, ROS unobtainable due to XXX"?

Thanks in advance,
Kirsten, CPC
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HPI, ROS and PFSH are all the components that make up the History. So, if the physician writes "HISTORY unobtainable due to..." it would appear to me that he is referring to all of the components in the History. It would be clearer if he did document each component separately, but I would take it as the entire History. :)

Thanks,
 
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