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ROS Auditing

  1. #1
    Default ROS Auditing
    Exam Training Packages
    When auditing Review of Systems in a note, can you count the documentation in the Past History toward that? For Example:

    Past History
    Cholecystectomy
    Hysterectomy
    Gall Stones



    Thanks,
    Tiffany Fischer, CPC, CEMC

  2. Default
    I would have to say no, this is clearly History. It cannot be counted in both ROS and History.

  3. Default
    My understanding is that you need to list in note something like " pt history cholecystectomy, gallstones, then it can be used as criteria for office visit medical decision making. My suggestion would be to indicate it under speicfic body system within ROS.

  4. #4
    Default
    No, this is not a review of system, this is just past history. Review of system is what is currently going on.

    You could have a ROS that looks like "patient no longer has periods due to a hysterectomy" but again the hysterectomy is going to be past history history and the lack of periods is the ROS.


    Hope this helps,

    Laura, CPC, CEMC

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