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Wiki ROS and PFSH reviewed

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wahmcoder

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Is there any documentation regarding a time limit on documenting no change of ROS or PFSH? For example my physician will document ROS and PFSH no change since XXXX but sometimes that is over a year away. You know how it goes I have to have documentation to dispute anything to them.

Thanks,

Samantha
 
Annual Physical vs sick visit

See my earlier post on this topic. It is entirely possible for a HEALTHY patient's ROS and PFSH to remain unchanged for years. (My own stayed the same for nearly 20 years.)

If it is for an annual physicial (no complaint) then it is entirely possible that there is no change at all and I would have no problem with referencing a previous report, even if it is over a year old.

If it is for a sick visit ... well, if the ROS is exactly the same why is the patient here? At the very least the documentation should state "ROS reviewed and unchanged from visit of mm/dd/yy except for HPI."

As a general rule and best practice policy, your patients should complete a new history questionaire annually. That would help to eliminate some of the references to older documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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