Wiki Credit for ROS

[mrsmason95]

PLEASE HELP!!

I have a Cardiologist that documents well, HOWEVER for a NEW patient or CONSULTATION, we are having a disagreement. For example: The CC will be coronary artery disease, he will document his 4 HPI elements, and end it with "There is no complaint of orthopnea, significant dyspnea, paroxysmal nocturnal dyspnea, palpitations, syncope and edema." Then he does his ROS and lists each one seperately:
General
Integument
Eyes
HENT
NECK
Respiratory
Heart
Abdomen
Lymph
Neurologic
psychiatric
Extremities

Did anyone notice that Cardiovascular (related to CC) is not listed?

He says that this is appropriate, but I disagree. Does anyone know for sure?? Again this is a new patient or consultation.

Also, for an established patient he will do the same thing, but he will include Cardiovascular in the list and state "see HPI". I've read that you can't state this for the ROS and then consider the same information recorded in one of the two places for both HPI and ROS.

I need an answer or something to reference to. Any input would be appreciated.

Signed,
Confused coder from GA

 

[FTessaBartels]

Assuming ...

Assuming he is actually completing information on each of the systems listed ... he's fine, because he has documented 10 or more systems in the ROS.

HOWEVER ... I would encourage him to list the systems as SYSTEMS - For example, he has HEART instead of CV; he lists ABDOMEN vs GI.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[JDACPC]

You can pull ROS from the HPI paragraph. He does mention palpitations which would cover for the cardiovascular ROS. "See HPI" or "As per HPI" is perfectly acceptable if it's actually documented in the HPI.

You're right about not using it for both HPI and ROS, you would have to use it for one or the other. In this example, if you use palpitations for associated signs and symptoms under HPI, you can't use it for cardiovascular ROS.

Hope that helps.