ROS?! Need answer ASAP!!!

anne32

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So the provider has a patient he is seeing for migraines, shoulder pain, and knee pain. The HPI talks about each problem individually and at the end of each he puts No Hx of trauma or Injury....Can this be counted as the ROS for each problem? I have nothing else for the ROS on this chart.
 
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So the provider has a patient he is seeing for migraines, shoulder pain, and knee pain. The HPI talks about each problem individually and at the end of each he puts No Hx of trauma or Injury....Can this be counted as the ROS for each problem? I have nothing else for the ROS on this chart.

When you say he "talks about each problem individually", what do you mean? For ROS, he needs to address specific body systems. "No Hx of trauma" on its own is not a review of any system.
 

gost

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ROS components can be taken from anywhere in the chart. They don't necessarily have to be labeled "review of systems". However, be careful not to double-dip - remember that you can't use the same bit of information for both the HPI and ROS unless it is clear from the documentation that the provider actually did review the system (ie. they didn't just write down the complaint with no follow-up).
 
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anne32

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What I mean is he has a paragraph for each problem. For example, shoulder pain- Patient has been experiencing shoulder pain for the past 2 years. It is worse in cold weather. Patient has some relief with Ibuprofen. No History of Injury or Trauma.

I am wondering if the "No History of Injury or Trauma" would count towards the musculoskeletal system.
 

thomas7331

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"No History of Injury or Trauma" is not ROS, it's PFSH. ROS consists of responses to questions the provider asks about various symptoms. Look for statements such as 'no nausea/vomiting' or 'denies fevers/chills' - these can be in any part of the note but usually in the history.
 
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"No History of Injury or Trauma" is not ROS, it's PFSH. ROS consists of responses to questions the provider asks about various symptoms. Look for statements such as 'no nausea/vomiting' or 'denies fevers/chills' - these can be in any part of the note but usually in the history.

Agreed.
 
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