trinalankford
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On the E&M worksheet, we can count a complete ROS *if* there is at least one system reviewed plus the statement "all systems negative except as marked".....and we know we can pull ROS elements from the HPI if not already accounted for.
However, if the only ROS element I have is in the HPI *and* the "all systems negative except as marked" statement is checked, does that constitute the "complete" ROS? Wouldn't there need to be another element checked in addition to the presenting system for it to be counted as a full ROS? Hopefully I'm explaining correctly.
Example: Patient came in with forearm injury, and I have location (forearm), associated S&S (loss of feeling, loss of ROM), context (wrecked ATV), and duration (just PTA). That is an extended HPI. There are no other systems mentioned in the HPI at all to pull down to the ROS section.
Can I count the "pertinent to 1 problem" as my single system?
Now that I'm writing this out, I'm confusing myself.
In a nutshell, I'm wondering whether I can count the ROS as a "complete" ROS if there is no other system available to pull from the HPI (and MD has marked the "all systems negative....").
If you can understand my gibberish, you're awesome. Thanks for any help!
However, if the only ROS element I have is in the HPI *and* the "all systems negative except as marked" statement is checked, does that constitute the "complete" ROS? Wouldn't there need to be another element checked in addition to the presenting system for it to be counted as a full ROS? Hopefully I'm explaining correctly.
Example: Patient came in with forearm injury, and I have location (forearm), associated S&S (loss of feeling, loss of ROM), context (wrecked ATV), and duration (just PTA). That is an extended HPI. There are no other systems mentioned in the HPI at all to pull down to the ROS section.
Can I count the "pertinent to 1 problem" as my single system?
Now that I'm writing this out, I'm confusing myself.
In a nutshell, I'm wondering whether I can count the ROS as a "complete" ROS if there is no other system available to pull from the HPI (and MD has marked the "all systems negative....").
If you can understand my gibberish, you're awesome. Thanks for any help!