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ROS Documentation-I am reviewing

  1. Default ROS Documentation-I am reviewing
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    I am reviewing an ER physician record and he documents ROS as "Negative except noted in the HPI".
    Does he get credit for all systems or none?

  2. Default
    In the HPI if he documents the pertinent ROS responses of the system the is related to the chief complaint, then this statement can be considered for a complete ROS.
    Jagadish, CCS-P, CPC

  3. #3
    Grand Rapids, MI
    He mentions the positives in his HPI, but how many systems in total did he review? Am I missing something here? It is early in the morning and I'm operating on only one cup of coffee so far.

  4. #4
    Quote Originally Posted by CMMORSE View Post
    I am reviewing an ER physician record and he documents ROS as "Negative except noted in the HPI".
    Does he get credit for all systems or none?
    It depends on how many ROS were noted in the HPI? Per the Documentation Guidelines: "At least 10 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 10 systems must be individually documented." It would also depend on your internal policy in your facility? Some auditors may think that statement is too vague, while others may think it's ok. Good luck.
    Evangelina Frohna, CPC, CEMC

  5. #5
    Question Ros
    Hi Evangalina,

    I work in a gastroenterology office in which I am trying to educate the providers on evaluation and management services. A provider asked me if a patient comes in to determine if they are a good canidate for a colonoscopy and there is not risk factors or symptoms for the HPI can we use no abdominal pain as location and no rectal bleeding as severity. My feeling is no. I would like your opinion. Kelly Griffin, R.N.C.P.C.

  6. #6
    I thought the ROS note had to be more specific. Like " All other systems were reviewed and are negative" or " All 10 systems were reviewed " If he simply puts - nausea- diarrhea -vomitting in the HPI then for the ROS puts "Negative except noted in the HPI" is that still allowable ?

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