Question Acceptable ROS/PFSH notation?

abaer01

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Melrose, FL
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My provider usually documents ROS/PFSH for establish patients as such:

PAST MEDICAL HISTORY, SOCIAL HISTORY, MEDICATIONS AND ALLERGIES: Reviewed and not changed since last visit.

REVIEW OF SYSTEMS: Reviewed in chart and signed.

Per E/M guidelines, the provider has to indicate that the ROS/PFSH was reviewed, and give the date and location of the previous notation. I don't believe "reviewed in chart and signed" is acceptable, but "reviewed and not changed since last visit" might be acceptable since he's pointing to the last visit and stating he reviewed.

Thank you.
 
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Orthocoderpgu

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You answered your own question, it does not meet documentation guidelines. An auditor would not give credit using that statement. Remember that coders deal with coding and compliance. As a coder it's your job to help keep your docs compliant and out of audit trouble. Also, you would expect it to change over time as the patient is being treated. If the ROS is not changing, is the patient being treated? The ROS performed should be commensurate with treating the patient on that specific date. If the patient is responding to treatment, the ROS should reflect that and for the most part it should not be necessary to perform a full ROS. I know your doc/s want a short-cut which is fine. Have them document the pertinent positive and negative findings ---for that date of service ---and if a full ROS was actually performed have the doctor document that "all other systems reviewed and are clinically negative". The ROS should change as the patient's medical condition responds or does not respond to treatment and it's not medically necessary to perform a complete ROS on every visit. Not long ago I audited an auditor, and three charts in I noticed that EVERY patient had a comprehensive history performed even though most of the visits were follow up visits. It was at that point I no longer gave credit for the History key component.
 
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