Wiki ROS question

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meganpoelzer

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One of the physicians I work for never documents a separate ROS. I know that we can pull out ROS from HPI and vice versa, but I would like to know if it is OK to use an item that is directly related to the CC.

For example:

"Patients words: Pt c/o rash around her stomach, lower right hip, and left arm. Pt sx have been present for 2 days. Also her for FOV on recurrent UTI's.

Rash was in several areas and is now gone. She did take an antihistamine. She brings a speck she thought was a bug but under magnifier is a piece of hair."

Would it be OK to use "c/o rash around stomach" as an element of ROS? Is it OK to use an element that is the same as the CC for ROS?

Megan Barber, CPC
 
Okay but ...

Yes, you can pull things from any part of the history as long as you don't use the same item for two things (can't use it for BOTH HPI and ROS).

BUT ... This is a perfect reason to have the patient complete a questionaire that includes the ROS and PMFSH and train the physician to always sign and review this document and reference it in his dictation.

F Tessa Bartels, CPC, CEMC
 
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