mhcpc
Guru
I am auditing a chart where the physian is unable to get a full review of systems because the patient has dementia. I think I read that I can give him credit for a comprehensive since he says in his note, "unable to complete because of patient's dementia" but I can't find it in writing anywhere. Can anyone help?
He also documents in the record that the rest of the history is obtained from the patient's spouse.
Thanks for your help!
Michele R. Hayes, CPC, CPMA, CEMC, CGIC
He also documents in the record that the rest of the history is obtained from the patient's spouse.
Thanks for your help!
Michele R. Hayes, CPC, CPMA, CEMC, CGIC