Forum - Questions & Answers

Apr 29th, 2015 - evandemark

If a physician states he is not able to get a review of system as patient is unresponsive and family is at bedside would you give him credit on an audit and what would you give him?

Apr 29th, 2015 - petunia 195 

re: If a physician states he is not able to get a review of system as patient is unresponsive and family is at bedside would you give him credit on an audit and what would you give him?

If you aren't able to obtain a history from a patient or other source due to the patient's clinical condition—being intubated, comatose or mentally impaired, for instance—document the specific reason why you could not take a history. You should be able to receive credit for a comprehensive history in such situations, but you may want to confirm that with your carrier.



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