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ED HPI, PFSH & ROS when patient has altered level of consciousness

Kelly Posted Wed 05th of September, 2012 16:15:26 PM

Would you give the MD credit for a comprehensive HPI, PFSH & ROS with this documentation?

Chief Complaint: ALCOHOL INTOXICATION--ED
HPI Comments: Cc altered level of consciousness, alcohol intoxication
EMS arrival
Found slumped against wall outside at local roadhouse
patient will respond and follow directions but is unable to stand or walk and has been retching with small amounts emesis
Admits to alcohol, denies drugs
BAC was 0.3 per EMS
Unable to get ros and further hx due to inebriation

Meds:
Previous Medications
No medications on file
Allergies:Review of patient's allergies indicates no known allergies.
PMH:
No past medical history on file.
No past surgical history on file.
History
Substance Use Topics
• Smoking status: Passive Smoker
• Smokeless tobacco: Not on file
• Alcohol Use: Yes
No family history on file.

Review of Systems
Unable to perform ROS: Mental status change

SuperCoder Answered Thu 06th of September, 2012 03:56:31 AM

Patient has altered level of consciousness and MD is unable to get Hx Information. Hence, this is considered as a caveat patient and HPI, PFSH & ROS can be taken as comprehensive with this documentation.

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