History of Present illness and ROS- only for Scoring purpose
By definition HPI is the description of the development of current illness (eg) date of onset ,how long it persists ,duration, when it get worst and whether radiating and so on and so forth. It is described by the patient; the provider must personally document.
Review of Systems is questions made BY THE PROVIDER and made to the patient to identify signs and symptoms that are operating in the systems of the body or being experienced in relation to the HPI.
The review of systems are systemwise elicitation(BY THE PHYSICIAN) with relevance to the CC, HPI and still other factors the physician elicits out of /finds out of the cumulative effect he obtained from the other elements. Though it can be obtained from CC and HPI to merit to ROS credits, the HPI cannot replace the Review of the various systems of the body which are authentically said to be reviewed by the Physician.
1. What I would like state is that the ROS can not be made up by us(the coders) by picking up from the HPI or CC or from here and there and place it for ROS scoring purpose; the ROS scores should be already made up and documented by the Physician, meaning, it isstandardised by her/him and already existing entity from her/him, whether s/he made it up from the CC or HPI, it is her/his responsibility to do so to complete it from anywhere,for which she /he is responsible. (For the Review of Systems, the physician can refer a sheet that he has in the patients chart where the physician checked off items)...
But now, what I understand from your threads, for scoring purpose of the review of systems (ROS), use of the system(s) addressed in the HPI for ROS credit can be acceptable; Well this cannot be said as double dipping. Is that you mean? Or are you trying to convey that from the document provided we can pick up some of the HPI and/CC and credit them for ROS merits for scoring purposes? Is that you mean?
This is the way I look into it. Can you consolidate all my facts supplied here and enlighten me what all the cook ups, breakups and make ups we can do and what all the provider could do sothat the document and the scoring system can tally each other, (with all its realities) which are legal and correct.
