The ROS is what the patient responds as to his symptoms or previous issues (or lack thereof) by system.
The Exam is a record of the direct observations by the physician on examining the patient TODAY.
They can't be mixed or used interchangeably.
I have seen physicians mix up their documentation.
EXAM: EOMI, naso/oral mucous membranes moist, some evidence of irritation/inflamation in right nasal passage. Patient denies any recent post nasal drip.. Lungs CTA bilaterally. RRR without murmur or gallop. Abdomen soft and nontender. Moves all extremities freely without pain. No edema.
The comment about the patient denying symptoms - even though it is reported in the exam section - COULD be considered ROS.
Hope that helps you.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join