ROS Help!! What is proper language for ROS?

jvalntine

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I would like to know if anyone knows were I can find information regarding correct documentation for ROS. My docs want to say "12 point review was done and is negative". I have told them this is not proper because it does not list pertinent positives and negatives. They want proof of where I found this information.

Also, they like to say "unremarkable" or "see HPI all others negative".

Where can I find legitimate rules for documenting the ROS?

Thank you
 

maudys

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Below are examples of what ROS documentation should reflect, taken from the 1995 documentation guidelines for E/M:

C. Review of Systems
ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.

There are three types of ROS:
1) Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system – the ear – is reviewed:

CC: Earache.

ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.

2) Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems – cardiovascular and respiratory – are reviewed:

CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.�

ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.
Evaluation & Management Services Guide 11

3) Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

CC: Patient complains of “fainting spell.�

ROS:
o Constitutional: weight stable, + fatigue.
o Eyes: + loss of peripheral vision.
o Ear, Nose, Mouth, Throat: no complaints.
o Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.
o Respiratory: + shortness of breath on exertion.
o Gastrointestinal: appetite good, denies heartburn and indigestion.
+ episodes of nausea. Bowel movement daily; denies constipation or loose stools.
o Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
o Skin: + clammy, moist skin.
o Neurological: + fainting; denies numbness, tingling, and tremors.
o Psychiatric: denies memory loss or depression. Mood pleasant.

You should also reiterate to the physicians that little golden rule, if it's not documented, it didn't happen.
 

dclark7

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This is directly from the CMS 1997 Documentation Guidleine for Evaluation & Management (pg 8) "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 indiviually documented."
www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf, www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
Above are the links to the 97 and 95 guidelines.

Doreen, CPC
 
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