Wiki Review of Systems

[fltbaroque]

Please help!

One of the physicians in our practice routinely uses this statement when making an initial hospital visit or consult:

"Review of systems: Reviewed. The patient's review of systems found on the patient's chart under physician documentation is noncontributory."

How could that even be counted as a review?

What would you do in this scenario?

Thanks!

 

[danskangel313]

IMO, the problem boils down to the fact that he states the systems were reviewed, but does not indicate the findings. Although he mentions a review of something in the pt's chart, we don't know what exactly it is that he's referring to. Without a statement as to what systems he reviewed and/or if the findings were negative or positive, just saying "Reviewed" doesn't elaborate enough to count as more than one system (the CC). "Complete ROS performed with no abnormal findings" is a totally different sentence than "Reviewed" if you know what I mean.

 

[fltbaroque]

IMO, the problem boils down to the fact that he states the systems were reviewed, but does not indicate the findings. Although he mentions a review of something in the pt's chart, we don't know what exactly it is that he's referring to. Without a statement as to what systems he reviewed and/or if the findings were negative or positive, just saying "Reviewed" doesn't elaborate enough to count as more than one system (the CC). "Complete ROS performed with no abnormal findings" is a totally different sentence than "Reviewed" if you know what I mean.

Those were my thoughts also. Thanks for your help!