Wiki Complete Review of Systems

[valerie2424]

Help - ASAP - REVIEW OF SYSTEMS
"A complete review of systems was performed and was all negative except for the systems as documented on the initial visit and those systems associated with the injury.?

Help, does the statement above qualify for a complete ROS? Or does there need to be a specific date for the referenced initial visit?

 

[midnightsun1369]

this is what the 1995 e/m guidelines state: (DG= documentation guidelines)

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
-describing any new ROS and/or PFSH information or noting there has been no change in the information; and
-noting the date and location of the earlier ROS and/or PFSH.

**full guidelines can be found on the cms website.

 

[valerie2424]

Thank you for your quick response. I am still wondering if the statement "A complete review of systems was performed and was all negative except for the systems as documented on the initial visit and those systems associated with the injury" would be considered complete as they reference the initial visit but do not give a specific date.