medicalsec
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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
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