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Wiki Review of System

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coder103

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Local Chapter Officer
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Will you consider counting a complete ROS, if doctor obtains 6 organ system in his notes and had noted/checked that he reviewed the complete (10+ organ system) assessed by the nurse? Why? Thank you for your input!:
 
With the proper reference to the nurse's note I would give the complete ROS. The physician does not need to record the ROS but needs to make proper reference to where it is recorded - e.g., see nurse _______ (name) note from _______ (date) - AND that s/he has reviewed it. Recording some of it and referring to another document for the rest should not be a problem.
 
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