Medicare history question
According to Medicare, what should the ER record state if the physician is unable to obtain a history from the patient or other source? My quess is to describe the patient's condition or other...
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Yes. "Patient unconscious, no family present, no hx available". Or something of that nature.Sharon
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Per the CMS 1997 Evaluation and Management Documentation Guidelines:If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition...
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Re: Medicare history question
Thank you Sharon & Steve for clarifying these issues.OMSPRO
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