Wiki Previous Review of Systems

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RebeccaClendenen

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In the absence of the previous review of systems documentation, would you credit a comprehensive review of systems with the following statement?

Past medical history and review of the systems as completed by him were reviewed during today's visit.

In the absence of proof of a prior comprehensive ROS, I have a hard time crediting this as "comprehensive" and it appears to me as though this may be a templated remark that is added to an EMR
 
I wouldn't credit it as comprehensive. The statement isn't clear.

What I suggest is something more along the lines of "Review of systems, past medical, social, and family history as completed by him on xx/xx/xx were reviewed and unchanged/changed. (If changed, the provider needs to explain..) provider initials/signature"
 
Thanks........ I'm really encountering a lot of problems with providers using EMR. This note also referred to the patient as BOTH he and she on multiple occasions. I'll admit that EMR's are easier to read and provide lots of opportunities for greater understanding, but when I see three pages of documentation for bunions and apthous ulcers (and i'm not kidding), I just want to scream
 
I agree.

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a
physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting
there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.

We recently moved to an EMR system. I zone in on fluff and cloning. I can't say enough...Medical Necessity.
 
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Established patient

If it's an established patient try coding using just the exam and MDM. You may not need the history (and muddlefutched as it may be) at all.

EMR sure seemed like a good idea ...

F Tessa Bartels, CPC, CEMC
 
My frustrations is that while I am sure it can be appropriate to say that a previous review of systems was updated, unless there is PROOF that the previous ROS was comprehensive, how can one assume that the update was comprehensive?
 
Because by specifying the date of the 'history (ROS/PFSH)' you are leading an audit trail. As long as the ROS/PFSH from the date you are referring to is comprehensive, you're fine. By not having that date, the reader has nothing they can refer to and can't assume it is comprehensive.
 
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