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Posted By Amanda on 12-22-2006, 16:20:00 in Ophthalmology
In our chart on the history side it states Alert/Orient x 3.

What does that actually mean? I was just recently auditing them and foung that no one including myself knew what that meant!!

Please advise!

Amanda
Comments (6)
Posted By Allison on 12-22-2006, 17:41:00
Most of this is observation and/ or can be obtained in casual
conversation. (eg. When you call there name in the waiting room, they
respond, obviously they know their name or "hi how are you today?" can
give your answer to mood and affect). Our assistance are taught that if
they are in question to the patient's orientation (ie. Dementia,
Alzheimer's) then they need to directly ask the questions.


Also, we observe young children and infants and document "age
appropriate" or inappropriate description of behavior.

Ali


Allison Benard

Eye-Q Vision Care

Fresno, CA
Posted By Amanda on 12-22-2006, 17:06:00
So do you actually ask these patient questions or is it an observation? I think we should probably be moving this to the exam side of our note then.

Amanda
Posted By Barbara on 12-22-2006, 16:45:00
It is part of the exam (neuro/psych) - orientation to time, place and
person. I have seen alert and oriented X 4 and the fourth one is situation.
It would not be counted in the history.



Barbara Rogers, CPC, RHIT
Coding, Compliance & Audit
Billings Clinic
PO Box 37000
Billings, MT 59107
1-406-238-5143
e-mail: brogers@billingsclinic.org
FAX: 406-238-5804
Posted By Allison on 12-22-2006, 16:44:00
If you look at the 1997 E&M single system exam for ophthalmology, it is
part of the exam not the history. It is listed an element that would
contribute to the level of care (E&M code) that you select.

Orientation to time, place, person

Mood & affect (eg depression, anxiety, agitation)

Both of these are listed as individual elements that you would count
when selecting E&M code.

Ali

Posted By Amanda on 12-22-2006, 16:36:00
Is that something that we need to be doing on every patient? Does that really count towards a history piece?

Amanda
Posted By Allison on 12-22-2006, 16:35:00
Who am I? Where am I? Year, date and/or time?

If patient is aware of these thethey meet the Alert and Oriented X 3

Merry Christmas!

Ali

Allison Benard
Eye-Q Vision Care
Fresno, CA
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