From CMS 1995 DOCUMENTATION GUIDELINES FOR EVALUATION & MANAGEMENT SERVICES
A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.
!DG: The patient's positive responses and pertinent negatives for the system
related to the problem should be documented.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
!DG: The patient's positive responses and pertinent negatives for two to nine
systems should be documented.
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
!DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is
permissible. In the absence of such a notation, at least ten systems must be
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