Wiki Provider review of ROS and PFSH

[dballard2004]

Per the CMS guidelines, the ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the information recorded by others.

Can someone tell me what exactly this notation has to say? Can it be something as simple as "ROS and PFSH reviewed?"

Does the provider's signature at the end of the note fill the requirements of CMS in attestation? Thanks.

 

[heatherwinters]

Supplementing or Confirming

http://www.cms.hhs.gov/MLNProducts/downloads/1995dg.pdf

there must be a notation supplementing or confirming the
information recorded by others

.


If it was documented by other staff, I would look to see if he added to it or wrote a statement such as "ROS positive for.."

See also the following
http://www.ahima.org/infocenter/documents/toolkit_appendixA.pdf#page=1

7. Providers are responsible for clearly identifying who performed each service documented within the note. When entering patient data into the medical record that the provider did not personally take or test, the provider must attribute the information to the person who did.
8. If the provider references a form within the record (e.g., review of system form), he/she must reference the form with sufficient detail to uniquely identify the source. Example: “For review of systems see form dated 1/1/08.”

 

[dballard2004]

Thanks so much! This is helpful.