Pediatric Coding Alert

Question: Do I need to list "No" for each negative review of systems (ROS)?
 
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 Answer: You might want to use an itemized checklist (available from the American Academy of Pediatrics or other documentation tool providers) as a tool to address systems. The patient can complete the list at a preventive medicine service, which makes future complete itemizing unnecessary.
 
For a complete ROS (at least 10 systems), you may refer to that previously completed list and then document all pertinent positive or negative responses with a notation such as "All other systems reviewed and negative." 
 
Example: If you see an infant with cough and repeated emesis for four weeks, you do not need to individually document all the systems reviewed. Instead, you could document the positive or pertinent negative responses to questions of emesis and stooling habits, as well as changes in activity level, and behavior for the relevant systems. To cover the other systems reviewed, you should refer to the previously completed list of systems and note, "All others negative." Make sure to keep the ROS checklist as a part of the record.

 -- Answers to You Be the Coder and Reader Questions answered/reviewed by Jack Percelay, MD, MPH, FAAP, a pediatric hospitalist at Virtua Health in Southern New Jersey; Peter Rappo, MD, FAAP, a practicing pediatrician and clinical professor of pediatrics at Harvard Medicine School in Boston; Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator.