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gquinn

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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?
WENDYR1

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Posts: 17
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.

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