Wiki ROS Confusion

[zgb49]

Can a Review of Systems be counted as complete if it appears as the following on a note:

Review of Systems
Below systems reviewed with the patient's wife, all are negative except as noted above
General ROS
Allergy and Immunology ROS
Hematological and Lymphatic ROS
Endocrine ROS
Respiratory ROS
Cardiovascular ROS
Gastrointenstinal ROS
Genito-Urinary ROS
Neurological ROS
Dermatological ROS.

Also, if the patient is unconscious or mentally disabled and it is noted that a ROS was unable to be obtained because of the patient's status, does that count as a complete ROS?

Thank You!

 

[Pathos]

The CMS E/M guidelines explain:

"At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented."

"DG: If the physician is unable to obtain a history from the patient or other source,
the record should describe the patient's condition or other circumstance which
precludes obtaining a history."

So in short, yes if the documentation supports it.