Sep 14th, 2015 - cmgmr 4
When obtaining HPI, ROS and PFSH from a patient in the ER is it appropriate to check "NA" for criteria when unable to obtain ROS due to altered mental status of the patient? The Neuro component is already addressed in the HPI, is AMS considered "Psych" under ROS?
Sep 14th, 2015 - abenet 5
It is really not appropriate to assume that the ROS is unobtainable. It is best if the Provider documents the ROS is unobtainable due to the AMS. Since an ROS is a question or questions with responses by the patient AMS is really not an ROS in this case, but more of an observation by the Provider.