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
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