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Wiki Chart Auditing - ROS

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mbdk1977

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I have recently completed an audit of some E/M codes and the group has a ROS, PFSH form. The patient and physician are most often times signing it but they are leaving it blank. Would you take that as having completed the review?
 
I agree with you, Lisa. It's hard to give credit for blanks. I know there are times when it's difficult to obtain this information (dementia, unconsciousness) but in normal circumstances, I feel an effort needs to be made. PFSH and ROS aid in the building blocks of the level of the e/m.

The ROS obtained on a previous visit does not have to be re-recorded, but all new information must be documented along with a notation stating where the previous information is located in the chart. Also, a review of the PSFH obtained during a previous visit does not have to be re-recorded but, again, new information must be listed along with a notation regarding the location of the previous PFSH.

Some type of documentation is needed to record pertinent facts, findings and observations about a patient. The physician will be held accountable for his documentation and as stringent as carriers are becoming, it's in his/her best interest to supply this information; but this only my opinion.
 
I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
i.e web sites, publications, etc.?
Thanks!
 
OB-GYN chart audits

Lana, you definitely want to get some OB-GYN specific chart audit training if you haven't done this before. You might check out the American College of Obstetrics and Gynecologists' Coding and Nomenclature web page http://www.acog.org/departments/dept_web.cfm?recno=6 and see if there are any chart auditing seminars/workshops near you that you could attend for some specialty-specific audit training. The AAPC might also sponsor chart auditing workshops that also provide CEUs so check with them too. Good luck!

LanaW said:
I am new to this practice - OB-GYN - and am expected to begin chart audits. I do not have any experience with this. Does anyone have any reference information they could pass along to me?
i.e web sites, publications, etc.?
Thanks!
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