Wiki Review of Symptoms on ER visits

[mrolf]

Our physicians are very lax in the documentation of the ROS on their dictated ER reports. They do mark box on the original ER form which states "reviewed nurses assessments by physician" and sign the form. I do believe that this is acceptable. Please advise on your thoughts. Thanks.

 

[lisigirl]

I believe this would work as well. Ancillary staff is allowed to document the ROS and the past medical/family/social history. As long as the physician acknowledges that he reviewed this, I say you're ok counting it.

Lisi, CPC