Review of systems question

tam0918

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We have an MD that is using the following in the ROS:Review of Systems: reviewed, see HPI for positives. How would you count this? Usually we see the negatives, this is throwing me off.
Thanks!
 

tmorgan808

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Without seeing the exact documentation I would say it depends on how in depth the HPI is and if you could pull and ROS from it. Because you can't do anything with the statement he is using.
 

vpat28

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ROS question

hello,
I have a medical record for review. The patient came in to see a Cardiologist for the first time. The patient states that he came in today because he wants a new cardiologist because of insurance.
Patient has a history of coronary artery disease, myocardial infarction,CABGx3 vessel performed at xxxx on 06/23/2015. Patient also has a history of HTN etc..

Provider did not document any ROS except Allergy. Provider did Detail exam and did EKG on patient.
So question here is Can we give credit for Cardio in ROS as the provide specialty is Cardiovascular?
Thank you in advance...
 

Orthocoderpgu

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A ROS is when the physician asks the patient about a certain system and the patient responds to the physicians inquire. So no, you don't give credit for Cardio ROS just because the physician is a Cardiologist. If the physician does not ask a question, and the patient answers, you don't have a ROS.
 
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