Review of Systems in Newborns

Yarbs

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Hello,

The following questions were posed by one of my clients - does anyone have the answer? My first instinct is to give the 10 pt ROS, as one would do for someone who is untubated or comatose. Also, for past medical history - would you give the pre-natal details or affirm that the child was just - born!
Many thanks -

1. With a newborn (age 28 days or less), what is required for documentation of the review of systems (ROS)?

2. More specifically for a high level admission (99223), does the MD need to document negatives and pertinent positives for 10 of 14 systems in a newborn?

3. If a re-admission is done, say, the kid goes home for 10 days then needs to be readmitted, does a new ROS need to be done or can they refer to the previous ROS and note any interval changes?
 
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The rules stay the same

To answer questions 1 & 2: There is no difference in the rules for meeting the key elements of ROS regardless of age of patient. So you need 10+ ROS for the highest level of service.

However, you can state that there is no ROS and give a reason. We ask our neonatologists who see the baby at birth to state something along the lines of: "Other than HPI, ROS is negative for this neonate on first day of life."
For Medical history we ask them to give the birth history.

As for re-admission ... you can always refer to records in the chart, as long as you clearly identify the records, that you reviewed them, when you reviewed them, and any pertinent changes. For example:
"Please see admission H&P dated mm/dd/yy, which I reviewed today; the only change is GI positive for diarrhea."

F Tessa Bartels, CPC, CPC-E/M
 
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Yarbs

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Thanks, Tessa!

That's very concrete advice, since in the 1995 and 1997 guidelines, it just says:

"For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children,adolescents and pregnant women may have additional or modified informationrecorded in each history and examination area.

As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate."
 
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