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Initial Hospital visit

  1. #1
    Default Initial Hospital visit
    Medical Coding Books
    When a Psychiatric does an initial hospital visit or consult for an inpatient (non-medicare) that is non-responsive verbally or limited response due to i.e. paranoia or psychotic condition, how should they document the inability to get ROS or a complete history? If there is family or significant other can they document recevied from them or prior clinical record?

  2. #2
    they should document it just as it is. Example- unable to get full history from patient as they are non responsive with XXX.
    Fmaily Hx obtained from his mother.

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