Wiki ROS in hospital

[KaylaRieken]

My provider dictated this:

I did review the review of systems done by Dr. A this morning. I agree with this and as per my HPI.

Do I give credit for this? Dr. A did a 14 point ROS.

 

[thomas7331]

This is answered in the CMS 1995 E&M documentation guidelines:

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.