AAPC - Back to school
Results 1 to 3 of 3

Thread: Documentation of ROS on new patient

  1. #1

    Default Documentation of ROS on new patient

    AAPC: Back to School
    We have a specialist that works out of our family practice clinic and using the same chart as the FP physicians. Specialist sees a patient for the first time and documents in his dictation that he reviewed the PFSH & medications that is on the face sheet in the front of the chart. Is this acceptable for an audit. Another scenario is where the specialist has the patient fill out questionaire which included the PFSH, medications, and ROS. Can the specialist state in his documentation that he "reviewed the PFSH, medications, and ROS" and this would be acceptable? The patient marks yes in the box related to the ortho part and either leaves the rest blank or marks no. I don't feel real comfortable with this, although sometimes he does mention the positive in the SOAP note but does not mention "all other ROS negative". Would this be acceptable for a complete ROS without the statement all others negatave. If someone could give me some answers on this so I can approach the specialist on this subject, it would be helpful. Thanks.

  2. #2
    Join Date
    Apr 2007
    Coastal Coders


    simply stating "all other ROS negetive" will not withstand an audit.
    The specialist needs only document that the PSFH and medications were reviewed.
    He does not have to repeat/reproduce them.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Ros & pfsh

    ROS and PFSH can be completed by anyone. However, in order to get credit, the physician MUST state that s/he reviewed the material and the location of that material. For example: ROS & PFSH from patient questionaire dated mm/dd/yy reviewed by me today and no changes noted..

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. ROS Documentation
    By Kreismann in forum E/M
    Replies: 6
    Last Post: 06-30-2015, 01:23 PM
  2. ROS Documentation
    By jackiemal in forum E/M
    Replies: 2
    Last Post: 12-03-2014, 03:55 PM
  3. ROS Documentation
    By CMMORSE in forum E/M
    Replies: 5
    Last Post: 07-15-2010, 09:04 AM
  4. ROS Documentation
    By OliviaPrice in forum E/M
    Replies: 2
    Last Post: 10-22-2008, 06:50 PM
  5. ROS documentation
    By todd5400 in forum E/M
    Replies: 11
    Last Post: 08-28-2008, 09:42 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.