Wiki Ros bundled into past medical/hpi

[medicalsec]

I can't seem to get one my my doctors to separate the ROS into a separate category to make it clear what he is doing. He describes the patient's previous conditions in the Past Medical History section, and discusses their symptoms in a "findings" section at the beginning of the report. He does not cover all of the systems in the "findings" section. I know that the rules say that the CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness, but he seems to be trying to use the past medical history/findings areas as the ROS. He does have a "Review of Systems " category in which he states that the review of systems is "otherwise negative" except for (states symptoms) pain, vomiting, etc. He does not use the term "all others are negative.

I know the proper way to do this, but I was wondering how a auditor would view this since he is referring back to discussion that took place in the other areas, and uses the words "otherwise negative."

Thanks,

Dee

 

[lisigirl]

I don't think it matters where you find the information within the note as long as its clear he is talking about the patients signs/symptoms (I've actually taken ROS out of the assessment and plan because the provider actually added a little more info on the patient's history while summarizing the case).

I do not think "otherwise negative" would fly as 10+ systems reviewed though. Our Medicare provider instructed that the provider must note any pertinent symptoms (negative or positive) and then write "all other systems negative" (as you said) to be give full credit under ROS.

You'll probably have an easier time getting your doc to change that one sentence rather than change the layout of his note.

Lisi, CPC

 

[Karolina]

I agree with lisigirl. It doesn't matter where in the note the items are documented so long as it is clear that the information is there.
"Otherwise negative" doesn't cut it for me, though. Better than "noncontributory" but far from "ALL other systems negative". I usually write the correct wording with question marks around it on the note and use it for training, but don't give credit for it.