Wiki ROS Auditing

[tfischer]

When auditing Review of Systems in a note, can you count the documentation in the Past History toward that? For Example:

Past History
Cholecystectomy
Hysterectomy
Gall Stones



Thanks,

 

[imjsanderson]

I would have to say no, this is clearly History. It cannot be counted in both ROS and History.

 

[gbrown]

My understanding is that you need to list in note something like " pt history cholecystectomy, gallstones, then it can be used as criteria for office visit medical decision making. My suggestion would be to indicate it under speicfic body system within ROS.

 

[LLovett]

No, this is not a review of system, this is just past history. Review of system is what is currently going on.

You could have a ROS that looks like "patient no longer has periods due to a hysterectomy" but again the hysterectomy is going to be past history history and the lack of periods is the ROS.


Hope this helps,

Laura, CPC, CEMC