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midnightsun1369

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Holden, LA
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Hello
Regarding ROS statement. The doctor documented this under ROS.

Review of systems at the current time is essentially unremarkable. Denies fevers, chills, cough, and shortness of breath.

Does this statement "essentially unremarkable" qualify as a complete ROS as all negative statement would?
 
Review of systems at the current time is essentially unremarkable. Denies fevers, chills, cough, and shortness of breath.
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We do not count that as a complete review of systems because it does not indicate "all" of the systems were reviewed. We educate our physicians that by stating only "review of systems" it leaves it open as to which of the systems were reviewed and it implies that some systems may not have been reviewed. According to the accepatable verbiage for a complete review of systems the statement is "all others are negative". We also teach them not to use statements such as "10 point review of systems" as that also does not imply that a complete reveiw was done, since there are 14 systems.

Hope that helps.
 
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