I found this in Medicare Report/March 1, 2005:
Q: If a patient is comatose or otherwise unable to provide a medical history, what does a physician need to document to obtain credit for "all others negative" in the ROS section of the History component?
A: When a patient is unable to communicate with the physician, credit will be given for a comprehensive History component (HPI, ROS, and PFSH), if the physician documents 1) Why the patient cannot communicate, and 2) What attempts the physician made in a diligent effort to obtain information from another source; e.g., a family member or nursing facility staff member.[/I][/I]
Maybe you can use this info as a starting point.
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