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Review of PFSH/ROS

  1. Default Review of PFSH/ROS
    Medical Coding Books
    Good afternoon forum,

    I had a question regarding reference of a previously documented ROS/PFSH in a shared inpatient chart. For example, the provider uses a consultation template that at the top says:

    Review : H&P Notes Subsequent Notes Nursing Flowsheets

    Since this is electronic documentation, they check a box.

    The provider may or may not add additional ROS or PFSH themselves.

    Would this be sufficient documentation to be able to utilize the ROS or PFSH in the H&P admission note or other notes checked off?

    As coders we are not to assume, and based on the documentation guidelines by CMS, I believe more documentation specifically stating review and updates is needed.

    Any opinions would be greatly appreciated!

    Thanks!

  2. Default
    Even though in EMR if box is checked for ROS and PFSH, there should be documentation as to how many ROS and PFSH were reviewed.
    Or at least notation stating - As per previous report all the ROS were reviewed and all were negative.

    Regards,
    Shruthi.

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