Wiki Using PMH for ROS?

[coder25]

Hello all,

As a newbie, I was wondering if it would be correct to use a PMH as part of ROS, if they did not include enough ROS? For example, diabetes to go under endocrine, arthritis for under musculoskeletal? Your thoughts?

Thanks in advance!

 

[lavanyamohan]

Hello all,

As a newbie, I was wondering if it would be correct to use a PMH as part of ROS, if they did not include enough ROS? For example, diabetes to go under endocrine, arthritis for under musculoskeletal? Your thoughts?

Thanks in advance!

Hello,
PMS not be taken for ROS. A person who suffered from CHF two weeks back, can now have regular rate and rhythm - Even glaucoma patients sometimes can have little decreased Intraoccular pressure . So, everytime it is necessary for the physician to interrogate the patient about his/her varying health problems and get this documented well.

 

[ARCPC9491]

As a last resort, I use the allergies from Past Medical History for the Allergic/Immunologic system if I don't have any other ROS

 

[RebeccaWoodward*]

Good Recommendation AR~

 

[FTessaBartels]

Documentation

Lavanya has a good point in that good patient care requires an appropriate history to include HPI, ROS and PMFSH. That being said, in my experience physicians do not always document in a "perfect way." (That's an understatement!)

I've seen notes that were one long paragraph and I had to read through carefully to separate out the history from the exam from the MDM.

Therefire, even when the physician has "labeled" his paragraphs HPI, ROS, PFMSH, I still use whatever I need wherever I need it for auditing purposes.

So there might be a long extensive HPI and I use part of that for past medical history or ROS. There might be an extensive past med history and I use part for ROS (or vice versa).

Hope that helps.

F Tessa Bartels, CPC, CEMC