Please see the HPI and ROS below:
HPI:
Patient presents to urgent care today with C/O swollen finger. Mother accidentally slammed child's left index finger in door 4 days ago. Mother concerned because finger is swollen and she states "I am getting pus out from under the nail". Finger was stepped on at school today as well. Child denies pain. Mother concerned finger is infected. Mother has been using antibiotic dressing to finger. Patients past medical history, surgical history and social history noncontributory to this visit. Family history reviewed and not pertinent to this visit.
Review of Systems: Musculoskeletal:
Left index finger swelling and nail loose
All other systems reviewed and are negative
The question is, can the 1 system (musculoskeletal) be counted towards the ROS and full credit be given for a Comprehensive ROS, or as it is the affected body part in the HPI , do you have to disclude this and the "all others negative" statement and give "none" as credit on the ROS (double-dipping)? -OR - Is it possible to use the 1 system, as it also states "nail loose" and this was not stated or used in crediting HPI?
HPI:
Patient presents to urgent care today with C/O swollen finger. Mother accidentally slammed child's left index finger in door 4 days ago. Mother concerned because finger is swollen and she states "I am getting pus out from under the nail". Finger was stepped on at school today as well. Child denies pain. Mother concerned finger is infected. Mother has been using antibiotic dressing to finger. Patients past medical history, surgical history and social history noncontributory to this visit. Family history reviewed and not pertinent to this visit.
Review of Systems: Musculoskeletal:
Left index finger swelling and nail loose
All other systems reviewed and are negative
The question is, can the 1 system (musculoskeletal) be counted towards the ROS and full credit be given for a Comprehensive ROS, or as it is the affected body part in the HPI , do you have to disclude this and the "all others negative" statement and give "none" as credit on the ROS (double-dipping)? -OR - Is it possible to use the 1 system, as it also states "nail loose" and this was not stated or used in crediting HPI?