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Review of Systems ROS) Template

  1. Default Review of Systems ROS) Template
    Medical Coding Books

    I'm working with a practice that requested sample templates or documentation of how the clinicians do an ROS on each patient. Historically, they were just stating that a 10 point Review of Systems was performed but it was not documented what those 10 systems were...

    I know that the physicians need to define which 10 body systems/organs they will review and document in the patient's record, and I understand that the 10 systems/organs identified by the physicians should be written up as a guideline or procedure that can be provided to an auditor if requested, but can anyone provide me with a screen shot of an EHR template or pdf of what your providers are using to document their ROS?

    Thank you in advance for your help!

  2. #2
    Baton Rouge
    The audit tool that I use lists these:

    1. Constitutional (weight loss, etc.)
    2. Eyes
    3. Ears, nose, mouth, throat
    4. Card/vasc
    5. Resp
    6. GI
    7. GU
    8. Musculo
    9. Integ
    10. Neuro
    11. Psych
    12. Endo
    13. Hem/lymph
    14. Allerg/Immun

    This is from the '97 Documentation Guidelines
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

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