Documenting Rx Allergies

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Can count as EITHER, but NOT both

It can count as EITHER ROS or Past Medical History, but NOT both (for the same note). Use it where you need it.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

kellyross

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I agree.... if you have enough in the Past Medical History already... I usually pull allergies into ROS, as well. :)
 

ajfinn0216

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I do not agree. Documentation of drug allergies should not be counted in the ROS.

A ROS should not be confused with the past history.

ROS asks the patient whether or not he/she is currently experiencing any symptoms related to specific organ systems.

Medical history is just that - the patient's past experiences with illness, operations, injuries and treatments. This would include a medication list, surgeries, previous hospitalizations, problem list, etc....

Angie Finnigan, CCS-P, CPMA, CPC
 

kellyross

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I would say if they were allergic in the past... then it would be safe to assume that they are still "currently" allergic. When questioning a patient about allergies - it would seem to be pertinent to the ROS and important in deciding the current treatment.... such as prescription management?

Also, Allergy/Immunology is listed as a valid body system to document on.

I guess it all depends how you're looking at it. I would still count it in my ROS if I already had a past medical history documented somewhere else.
 

kellyross

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a couple excerpts from 2 diff references

***** these infer that medication allergies are fair game for ROS*****

Allergic/Immunologic/Lymphatic/Endocrine Reactions to drugs, food, insects, skin rashs, trouble breathing
Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy, growth, secondary sexual development, intolerance to heat or cold

Allergic/Immunologic/Lymphatic/Endocrine Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results.
 
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