Ros

geugene

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Does stating "ROS unobtainable due to patient being a unreliable historian" count?
 
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Maybe

I'd want to see more of the note to be sure, but it's possible.
Why is the patient an unreliable historian? Dementia? Young child? Currently intoxicated? Recent head injury?

F Tessa Bartels, CPC, CPC-E/M
 

geugene

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I have typed the HPI & ROS of the note.

CC: Right-sided weakness

HPI:
60-AA man. Prior stroke, who transferred from nursing home earlier today with rt. upper & lower extremities weakness and, as of today unable to walk. Pt unable to provide must of history so it's taken from ER physician history & chart review. Possibility of a stroke, given pt. history. Pt. developed right-sided weakness on Friday, which worsened over the weekend. The remainder of the history of present illness at this time is unobtainable.

ROS:
Unobtainable at this time. The pt denies any obvious symptoms, but is somewhat unreliable in his history.
 
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the only ROS I see is musculoskeletal (weakness-unable to walk)

I have typed the HPI & ROS of the note.

CC: Right-sided weakness

HPI:
60-AA man. Prior stroke, who transferred from nursing home earlier today with rt. upper & lower extremities weakness and, as of today unable to walk. Pt unable to provide must of history so it's taken from ER physician history & chart review. Possibility of a stroke, given pt. history. Pt. developed right-sided weakness on Friday, which worsened over the weekend. The remainder of the history of present illness at this time is unobtainable.

ROS:
Unobtainable at this time. The pt denies any obvious symptoms, but is somewhat unreliable in his history.
 
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Taken from chart?

Your doctor writes:
Pt unable to provide must of history so it's taken from ER physician history & chart review Is there history in the chart that you can use for ROS? (including nursing home notes, if he was transfered, they may have come with him)

From the note you have and depending on how much you need for HPI ... you could use "prior stroke" as Neuro ROS and "unable to walk" as musculoskeletal.

F Tessa Bartels, CPC, CPC-E/M
 

RebeccaWoodward*

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We experience this frequently. Many of our providers are unable to obtain this information due to CVA's or head trauma (etc). In these situations, my providers have been instructed to document the cause or event for the lack of this information. For example, if a patient is intubated, the providers dicatation will indicate something like this..."Patient intubated due to CVA and unconscious ; unable to obtain ROS". Our Medicare carrier does allow this/these statements and credits a full ROS.
 
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