It would help to see the actual note / wording of the reference.
But in general, yes, the physician does not have to complete the ROS him/herself, but can refer to a questionaire or other record in the chart where a complete review of systems has been done - AS LONG AS ... the physician must refer to the specific document ("see nurse's note" is NOT sufficient) by date and who completed it, AND must state that s/he (the physician) reviewed this document and concurs - even better list separately any pertinent positive or negative items.
So, for example, let's say you have a patient who presents with diarrhea and stomach cramping. The nurse fills out the ROS questionaire (all 14 systems reviewed). The doctor might say something like: "I reviewed the ROS questionaire today and of note: only previous GI problem was appendectomy at age 6, no recent fevers or unexplained weight loss or gain. For the remainder of the review of systems, please see the ROS questionaire completed by nurse A mm/dd/yy."
The Review of Systems requirement is the same whether using 1995 or 1997 guidelines.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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