Wiki Review of Systems

[mdm58]

My question is if the pt fills out the review of systems questionnaire. And the Dr (Cardiology) in his dictation list hard of hearing in his review, and states ROS reviewed with pt. And that's all that is in his note. Can he count that as a complete ROS?


If anyone has an answer for this question could you please email me @ mmunsey@utmck.edu Thanks

 

[CodingMari]

I am not sure if anyone reply to you in regards to your question. if they did i would like to hear about it since I am also seeing this too.

 

[Chelle-Lynn]

It can be considered as a full review of system with the following criteria:

- The questionnaire is entered in the chart as part of the medical records
- If the provider documents reviewed questionnaire with patient; notes any issues as part of his documentation; and indicates all remaining systems within normal limits or no issues

It is common now a days to have the patient complete the ROS questionnaire as part of the record, but the key to allowing the use of this documentation for leveling is how the provider identifies the use of the questionnaire in his/her personal documentation.

 

[CodingMari]

thank you! I appreciate the feed back.