Question How to count Review of systems for intubation

wynonna

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Hinsdale, MA
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Under ROS our MD documents :"limitations: clinical conditions" because intubated patient can't respond to questions for ROS.
So unfortunately pt is intubated and has epistaxis.
History section documents that pt was observed bleeding from nose and mouth during transfer from ER to ICU.
Can we count any points under ROS from the above statements?
How do we count points under ROS when patient is intubated, or is that automatically a Problem-focused history?
thank you
 

kimberlywatson

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Brentwood, TN
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If the provider documents a reason for not being able to obtain a certain part of the history, it doesn't count against him so he gets full credit.
 
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