Registered: 1508934500 Posts: 2
Reply with quote #1
Where is it documented that we can give full credit for the ROS when the patient is sedated and/or intubated? I have seen conflicting view points on this matter. Is this only for patients seen in the ER/ED departments? Additionally, how should this be documented? will a simple comment of "Sedated, intubated" in the Exam under general appearance be sufficient?
Registered: 1463057094 Posts: 13
Reply with quote #2
If you look at the 95 or 97 guidelines it states:
DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance that precludes obtaining a history.
To be clear, I would ask the provider to document "Unable to get an HPI/ROS as patient is sedated/intubated". They get history from somewhere so they should document where/from whom.