Wiki no pain as ROS?

[jeskla]

Hello,

Would anyone count "she has no pain" as ROS in the SOAP note below? My physician and I are disagreeing.

Subjective: XX presents today with Mom for follow up on her left knee. She is doing much better. She has no pain.
Physical Examination: On exam she can do a single-leg hop in the office and a deep knee bend without pain. The left knee is ligamentously intact.
X-Ray Data: None taken.
Assessment: Left knee chondromalacia patella.
Plan: She does have some underdevelopment of the VMO on the left compared to the right. It is important that she works that out. Otherwise, her knee issues will continue to be a problem for her. She will be doing her exercises on her own. We will see her back in the office as needed.

 

[Pathos]

I suppose you could put "no pain" under Constitutional, but the provider should probably be more specific when documenting pain, ie. location. The provider might argue that the "no pain" statement is referring back to the knee, but this argument is not ironclad.

That said, I wouldn't feel 100% comfortable using "no pain" in any of the ROS elements without further elaboration in the note.


Additional reading:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf