Wiki ros question

[mshelly87]

when our dr sees a patient and say the note says denies chest pain, orthopnea sob in the symptoms part but then under ros says please see ros in chart from today and does not comment on pertinent positives or negatives does this count as a comprehensive review of systems? we have our follow up patients and new patients fill out a complete review of sytems form every visit then keep it in the chart.

 

[jimbo1231]

Not Quite Enough

I don't think see ROS is a strong enough statement by the physician to use the form since it doesn't establish that the physician reviewed the form. I would be looking for something more like "reviewed form and concur with ROS". It also wouldn't hurt if he added a specific comment.
The doc did note two pertinent negatives. Why was the patient there and were they still experiencing any symptoms? To get some positives if there were any.

Jim

 

[krssy70]

I agree with Jim. The doc would have to have some kind of documentation that he reveiwed the ROS on the pt form and agree/disagree. Can only count comprehensive if the doc listed 10 Ros, neg or pos, or listed the positives and then documented all other negative.

Kristen