ROS help, please.

solocoder

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Need some opinions on this ROS, please. How would you count this, if at all?
On top of that, the ROS in the note I am trying to code today say this previous ROS from another physician is they one they "reviewed".


CHIEF COMPLAINT: Left foot red, swollen. Patient on antibiotics, Keflex, with no improvement, given to him by doctor at urgent care center on Friday. No chest pain. No shortness of breath. No nausea, vomiting. No headache. No dizziness. Patient has a history of diabetes and myasthenia gravis. Was given the antibiotics in the ER. Patient is also on steroids. Left foot is red, swollen, painful, progressively worse over the past few days. Patient has been treated for cellulitis. He was on clindamycin. He was compliant with his medication. It is also to the plantar surface of foot that began about 2 months ago. He was recently diagnosed with myasthenia gravis a few months ago. He has chills, but no fever. No dysuria. No bright red blood per rectum. No abdominal pain. No recent travel.
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10-POINT REVIEW OF SYSTEMS: Other than HPI, negative.
 

twizzle

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Need some opinions on this ROS, please. How would you count this, if at all?
On top of that, the ROS in the note I am trying to code today say this previous ROS from another physician is they one they "reviewed".


CHIEF COMPLAINT: Left foot red, swollen. Patient on antibiotics, Keflex, with no improvement, given to him by doctor at urgent care center on Friday. No chest pain. No shortness of breath. No nausea, vomiting. No headache. No dizziness. Patient has a history of diabetes and myasthenia gravis. Was given the antibiotics in the ER. Patient is also on steroids. Left foot is red, swollen, painful, progressively worse over the past few days. Patient has been treated for cellulitis. He was on clindamycin. He was compliant with his medication. It is also to the plantar surface of foot that began about 2 months ago. He was recently diagnosed with myasthenia gravis a few months ago. He has chills, but no fever. No dysuria. No bright red blood per rectum. No abdominal pain. No recent travel.
*
10-POINT REVIEW OF SYSTEMS: Other than HPI, negative.

This would qualify as an extended ROS (2-9 systems). To say 10-point ROS (I feel) is meaningless because the systems reviewed are not documented. If they had said that apart from what is documented in the HPI all other systems were reviewed and were negative, that would qualify as a complete ROS. Provider reviewed CV, Resp, GI, GU, Const, Neuro.
To say the previous ROS was reviewed without documenting anything is also meaningless. ......nevertheless, you have an extended ROS here. The information could only have been obtained by asking questions which is the basis of a ROS.

Hope this helps.
 
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