Wiki Unable to obtain history

[svrastil]

Can someone help? I know that medicare has on their website that you have to document why you were unable to document the HPI. But it does not tell me if I can use Comprehensive for the History.

 

[RebeccaClendenen]

unsure if this has been clarified

I have been told that this is considered the "ER Caveat" and that it was supposed to be implemented with the 2000 guidelines which were tabled without implementation. I believe you can probably get by with it as a comprehensive, but it may be up to interpretation by the auditor and be prepared to defend it with ample documentation. The documentation should bear out why you are unable to obtain history, and should explore any of the options that the provider had considered (patient's family, family doctor or whatever) that weren't fruitful. If the patient is intubated, they aren't necessarily unable to communicate, unless they are being sedated or comatose, and so document that as well.

 

[Karolina]

I have an Audit tool from NHIC from which I'd like to quote:

"Important Note: Allow a comprehensive history if the physician is unable to obtain a history from the patient or other source. The record should describe the patient's condition or circumstance that precludes obtaining history."

To answer your question: Yes, you can give a comprehensive history if the provider was unable to get a history AND documented why. Simply stating that a history could not be obtained is not enough.