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ROS-constitutional question

  1. #1
    Question ROS-constitutional question
    Exam Training Packages
    If a physician documents in the HPI: 69 year old male (plus additional information directly concerning the reason for the visit) but gives NO ROS, can I count the 69 year old male in the constitutional area of the ROS?

  2. #2
    Location
    Ellenville, New York
    Posts
    1,176
    Default I would not do so
    Quote Originally Posted by sherylborkowski View Post
    If a physician documents in the HPI: 69 year old male (plus additional information directly concerning the reason for the visit) but gives NO ROS, can I count the 69 year old male in the constitutional area of the ROS?
    Since this doesn't describe a general condition or appearance - instead it is a indentifier - I would not use this information for the ROS.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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