review of systems

[Jenna000]

Any one have any input on Drs using the remark unremarkable in the review of systems.

thanks

 

[RebeccaCross*]

Any one have any input on Drs using the remark unremarkable in the review of systems.

thanks

I do not allow it. I would check with your MAC...



Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

Answer:
No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).

Resource(s):

E/M Documentation Guidelines

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction-11-Part-B~8EEM6K6862


last updated on 06/03/2014

 

[Jenna000]

Rebecca,
you mentioned for the past medical, family, and social history, but does this apply for the review of systems as well?

 

[RebeccaCross*]

As you know, the ROS in an inventory of the negative/pertinent findings. "Unremarkable", to me, does not provide a positive/negative finding. I strongly recommend that once the provider records his findings, he documents a statment something like... "All other systems were reviewed and are negative." This is, of course, if the information was actually reviewed and pertinent to the reason for visit/chief complaint. E/M University has some other helpful hints...

http://emuniversity.com/ReviewofSystems.html

Hope this helps...

 

[Jenna000]

it does, thanks. We do not accept when they use it either, just wanted more documentation...or having someone else say it always help.

thanks again,
jenna