Wiki Hpi/ros

[sluke9]

Question about ROS. Our physicians state "As noted in the history of present illness; all other systems are negative" for the ROS. If they are stating 'pertinent negatives - no breathing difficulty, no N & V (as examply), would anyone say you could pull that for a 2nd ROS?
Thanks!

 

[MikeEnos]

If I'm understanding what you're saying, then that is a complete ROS. If the HPI states positive and pertinent negative ROS findings, and the ROS states "as in the HPI, all other systems are negative" then that satisfies the criteria for a complete ROS as per CMS.

Now, if they routinely state that phrase for their ROS, but the HPI doesn't include positive and pertinent negative findings, then it is not acceptable. So be careful that this documentation shortcut it isn't misused.

 

[sluke9]

In the HPI once in awhile they will say 'pertinent negatives -none or something like 'pertinent negative -no N&V' etc. They don't always list pertinent negatives in the HPI. The ROS entry always says 'As noted in the history of present illness; all other systems are negative'. We just want to make sure that this is enough to pull out of the HPI to use as part of the ROS.
This is an example:
Mechanism of injury: punched friend on the knee
Severity of pain: moderate
Numbness: denies
Tingling: denies
Weakness: denies
Associated symptoms: none
Pertinent negatives: none
Other injuries: denies
Prior treatment: none
Last tetanus booster: within the past 5 years

REVIEW OF SYSTEMS:
As noted in the history of present illness; all other systems are negative