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Wiki Help with ROS & PFSH

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Chelsea1

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When counting the ROS and the PFSH can you count the face sheet that the M.A. fills out that includes the patient's blood pressure, smoking history, ROS details in the patients chart for that encounter if the doctor signs the bottom of the page but doesn't put the details in his consult or patient follow up letter?
 
Chelsea1 said:
When counting the ROS and the PFSH can you count the face sheet that the M.A. fills out that includes the patient's blood pressure, smoking history, ROS details in the patients chart for that encounter if the doctor signs the bottom of the page but doesn't put the details in his consult or patient follow up letter?
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The provider has to document the results/information from the face sheet as far as BP readings, etc. If there's additional information like questions about systems, the provider would have to inquire about them based on what the patient marked on the sheet. The documentation has to include a patient response; for example if the patient marks that he/she is having "wrist pain", the provider has to ask questions pertinent to that and document accordingly.
 
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