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Wiki Using HPI for ROS

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sunshinepink

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If the doctor documents the following:

History:
Jane Doe is a 52 year old female
Patient presents with:
DRY EYE - pt requesting ref to opthamology

Had lasik 2 yrs, now complains of 1 year of dry eyes and 2 weeks of eye redness. Uses over the counter drops for dry eyes already.

- can you use eye redness for ROS
Is there any clear documentation on what is applicable to be used from the HPI for the ROS
 
It depends on how much HPI you need

Depending on what level of E/M your looking at ... you may only need 1 element of the HPI ...so, yes, I'd use anything else not needed for the HPI towards ROS. )I'm assuming that there is no clearly identifiable ROS listed elsewhere.)

F Tessa Bartels,CPC, CPC-E/M
 
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well - before I would have said "no" - but I've since learned, that yes you can :) (see, you can teach an old dog new tricks) ;) I agree with Tessa and Rebecca - yup, I too would use it in the ROS if needed and 'not' already used in the HPI ..
 
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