Ros
Hi
The ROS statement has been a controversial topic over the years, but what I have learned is this; first and foremost it is best to check with your MAC to see what statements "they" prefer providers to use. Because in the long haul, they are the one's you are really trying to abide by in case of an audit. I perform audits for different regions and while most accept the same general statement as designated in the 1995/1997 Guidelines, Some do prefer to have the reference to a specific total, ie. "10 point ROS performed and was negative". But, they will also require that pertinent negative/positives must be noted in the HPI for this to be accepted. The fact still remains that - The 1995 and 1997 DG indicate, "a complete ROS inquires about the system(s) directly related to the problem(s) identified in the History of Present Illness (HPI) plus all additional body systems." The DG also state, "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 individually documented."
When in doubt always refer to these guidelines and your MAC for help. Chances are you will find what you are looking for. Hope this helped instead of overwhelmed! lol