ladybird
Contributor
Hello,
I have a question of acceptable documentation for ROS.
Here is the scenerio: HPI :
She had an EMB (endometrial biopsy) done for PMB(Post menopausal bleeding). She is done with childbearing and if results are abn she desires to have it all removed. She has had a D&C in the past and is familiar with the surgery.
ROS: Comprehensive ROS was neg with the exceptions in HPI.
I don't feel that the expections in the HPI is sufficient documenation, for the abnormal findings and the HPI doesn't have any ROS.
Please advise.
I have a question of acceptable documentation for ROS.
Here is the scenerio: HPI :
She had an EMB (endometrial biopsy) done for PMB(Post menopausal bleeding). She is done with childbearing and if results are abn she desires to have it all removed. She has had a D&C in the past and is familiar with the surgery.
ROS: Comprehensive ROS was neg with the exceptions in HPI.
I don't feel that the expections in the HPI is sufficient documenation, for the abnormal findings and the HPI doesn't have any ROS.
Please advise.