Wiki Giving Credit For Allerergic/immunologic in ROS


Baton Rouge, LA
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Can anyone clarify if we are allowed to give credit if the documentation states NKDA or is it specifically states what the allergy is. I have consulted with co-workers on this and we are trying to find were it is documented that we can give credit in that area. We did find documentation stating that you can not give credit unless the physician documents "negative". If they only document NKDA or if that just state what the patient is allergic to with out the status “patient currently having no reactions" ,we are not allowed to give credit.
My understanding is that it depends on where in the process you are reviewing allergies, and how these data are documented. In ROS, the 1995 Guidelines state, "A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." Here, it is just a listing that tries to capture additional detail about how these data may impact the CC, exam, or medical decision making, so documenting NKDA is permitted. PFSH requires more detail. 1995 Guidelines state, "past history (the patient's past experiences with illnesses, operations, injuries and treatments); family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk)." Exam requires still more detail. In the exam, systems and/or body areas must be evaluated, and findings documented. 1997 Guidelines will give you specific elements to include in the documentation.