You Be the Coder:
Is Allergy Part of ROS or History?
Published on Thu Jun 03, 2010
Question: The provider documented NKDA (no known drug allergies) as part of a patient's evaluation. Can we count this as part of the "allergic" portion of review of systems? Michigan SubscriberAnswer: The correct place to document allergy status depends on the patient's situation. Consider an active allergy as part of the review of systems (ROS); classify the allergy as part of the patient's past/personal history if the allergy is not currently present but might be related to the chief complaint.Caveat: Exceptions pertain to ongoing circumstances such as a penicillin allergy. Always consider this type of allergy "active" because administering a dose of penicillin to test the status might kill the patient.