Wiki Auditing Help

Create Wiki
Two different things

The ROS is what the patient responds as to his symptoms or previous issues (or lack thereof) by system.

The Exam is a record of the direct observations by the physician on examining the patient TODAY.

They can't be mixed or used interchangeably.

HOWEVER ...

I have seen physicians mix up their documentation.
e.g.
EXAM: EOMI, naso/oral mucous membranes moist, some evidence of irritation/inflamation in right nasal passage. Patient denies any recent post nasal drip.. Lungs CTA bilaterally. RRR without murmur or gallop. Abdomen soft and nontender. Moves all extremities freely without pain. No edema.

The comment about the patient denying symptoms - even though it is reported in the exam section - COULD be considered ROS.

Hope that helps you.

F Tessa Bartels, CPC, CEMC
 
You must log in or register to reply here.
Top