Wiki Help with ROS statement

[peanutbutterkisses]

Please review the ROS statement below and let me know if you consider it specific enough to give credit for a complete ROS. A few of my physcians use variations of the all systems reviewed and negative unless in HPI and I am not sure how I feel about it.

Thanks

CHIEF COMPLAINT:
Fever, Short of breath, Syncope

HISTORY OF PRESENT ILLNESS:
49 yr old male here c/o 4 days hx of fever/chills. Has had a productive cough
with yellowish blood streakish sputum. States he is short of breath and is
having chest soreness due to the excessive coughing. Has been taking Thera-
flu
at home with no relief in symptoms. No N/V/D. States yesterday on 2 occasions
passed out after a coughing spell. Has been feeling a bit dizzy as well. Does
admit to a prodromal of dizziness. No focal weakness/numbness. No speech
changes. Does c/o diffuse bodyaches. No sick contacts.

REVIEW OF SYSTEMS:
All systems have been reviewed, were deemed negative, unless specifically
mentioned in the HPI.

 

[smithbettye]

It's enough.

 

[debflutter]

It is only enough if you don't have to count what is in the hpi to establish a level in the hpi. You can count anything twice.

 

[gailgordon314]

I tell my clinicians to bring out one pertinent negative or positive regarding the HPI and then say all other systems are negative except as noted in the HPI.

So if the HPI states something like Patient presents with sore throat over 4 days. OTC not helping.

The ROS would say something like: ENT: patient states ears are ringing. Respiratory: does not complain of cough
All other systems are negative except as noted in the HPI.

 

[peanutbutterkisses]

Gail,

That is what I would like to see, and am working on getting all of the dr's on the same page. In the meanwhile, I flip flop as to whether that statement is sufficient.

 

[gailgordon314]

PBK this will help

CMS 1995 and 1997 Documentation Guidelines both state that after pertinent positives and negatives have been addressed, the statement "all other systems are negative" meets CMS documentation requirements for a complete ROS.

Reference: http://www.acep.org/content.aspx?id=30474

 

[MnTwins29]

Even if you are looking for a pertinent positive and negative, there is certainly enough in the HPI that the statement is fine. Just for the SOB - you can use that, or if you want to use that as HPI and not count it as ROS, what about the soreness in the chest from excessive coughing? Certainly enough there for a HPI element and a pertinent positive ROS finding. Remember, the documentation doesn't have to be labled specifically as "ROS" or "HPI" to count for those.