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I have a provider that documented in th exam the following:

GI-upset w/ Ibuprofen
Headache w/Skelaxin
Dry mouth w/Flexeril

Can all of that count as part of the exam or is it patient history? Thans in advance for anyone's guidance.
 
ROS? Past Medical?

Sounds like a response to "any adverse reactions to drugs?"

The "side effects" listed don't really seem to be allergic reactions (if they were true allergies you could count as ROS). I'd be inclined to count as Past Medical History.

F Tessa Bartels, CPC, CEMC
 
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