# ROS for dermatology. Please help



## JesseL (Oct 9, 2013)

What level of history would this fall under?  I work for a dermatology practice that uses Ederm and this is what most of the history portion of the documentation usually looks like.  To me there's only one ROS because I'm thinking the negatives don't count? Would this just be expanded problem focus then?

Chief Complaint and/or History of Present Illness
Complaint(s):
1. Growth on left cheek
Symptom: no pain, itching and or bleeding
Duration: few weeks
Severity: worsening
Modifying Factors: none

Past History
Past Medical History (PMH):
• Denies artificial joints or heart valves, diabetes, glaucoma, hepatitis, hypertension, immunosuppressed, pacemaker,
antibiotics prior to dentistry, skin cancer, hiv/aids, hyperthyroidism, hypothyroidism, lupus, polycystic ovarian
syndrome, blood clot, cancer, kidney disease, asthma and hayfever
Family:
• Admits family history of Acne (sister)
• Denies family history of cancer, malignant melanoma, eczema, lupus, non melanoma skin cancer and
psoriasis

Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary

Social:
• Admits: Alcohol Use (social)
• Denies: Illicit drug use, profession, tobacco use
Surgical History
• Denies cancer surgery, gi surgery, plates/rods/screws/stents, heart surgery and joint replacement
Allergy:
• Patient denies allergy to medication
Medications:
• Patient denies taking any medication


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## Narayana (Oct 10, 2013)

U have to  count Negative ROS. because physician reviews the systems, then only he came to those systems are Negative.


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## Squiabro (Oct 10, 2013)

JesseL,

The "ROS" is complete as all systems were "reviewed" and documented as "negative" by the provider. The history is EPF.


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## JesseL (Oct 10, 2013)

Wouldn't it be detailed history if the negatives count? 2-7 ROS for detailed right?


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## mhstrauss (Oct 10, 2013)

JesseL said:


> Wouldn't it be detailed history if the negatives count? 2-7 ROS for detailed right?



It's 2-9 Systems for Detailed ROS; 10 or more is Complete.


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## MikeEnos (Oct 10, 2013)

Yes, you can count negative findings on the ROS.

I get a Comprehensive history from what is documented.

Extended HPI
Complete ROS
All 3 elements of PFSH


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## JesseL (Oct 11, 2013)

thank you for the responses


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