Review of Systems - cheif complaint

solocoder

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Does a review of systems have to reflect the cheif complaint? I mean if the cc is "foot pain, bunion", does the ROS need to say Musculoskeletal: foot pain?? or bunion?? One of our doctors uses a questionaire to get the info for his ROS and if the patient does not answer YES to his specific questions, their ROS could show NEGATIVE for every system. Wouldn't that leave you wondering WHY they are here?
Appreciate any thoughts.
 
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Milwaukee WI
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Depends

This depends on how your questionaire is worded and how the physician documents his/her review of that patient-completed information.

It also depends on how your carrier considers "duplicating" this information from HPI and ROS.

Some carriers want something OTHER than the HPI listed in the ROS ... could be same system but they want a different problem. For example: CC is bunion right foot
ROS for musculoskeletal is negative for problems with gait or muscle weakness

Some carriers will allow the positive finding for the CC to be also reflected in the ROS - for example: ROS all systems reviewed and negative except as noted in chief complaint and HPI.

I know that's not the definitive answer you'd hoped for, but I hope it helps.

F Tessa Bartels, CPC, CEMC
 

losborn

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As an auditor, if the CC contradicts the ROS, I question if any of the ROS was done at all. I have the same feeling if the Exam contradicts the ROS. Say the exam states SOB, rails, cough, but the ROS says Resp. system is normal - or "all systems normal."
Especially in an EMR, I woder if any ROS was done at all.

Of course, the rest of the record has to be taken into account, and E/M is notorious for its grey areas. Seeing a red flag does not necessarily mean the ROS should automatically be counted out.

Lin
CPC, CEMC, CPMA
 
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