Wiki Patient with dementia

[pittiemom2722]

We had a new patient come into our office from a local nursing home facility without much ppw unfortunately or send the radiographs that they were supposed to send along with her. She has dementia. When our provider tried to examine her, she was not able to communicate any signs or symptoms, give any sort of history, chief complaint, etc. Although the exam was completed, how do we get credit for the rest of the areas since the patient was not able to provide the rest of the information and the facility didn't send any information?

Thank you!

 

[AmandaBriggs]

I advise my providers to document what they can and to include a statement such as, "Unable to obtain a history of present illness, review of systems, or PFSH due to patient's dementia. No other caregiver present." This shows that the provider tried to obtain the information and that there was nobody else with the patient who could help provide the details.