Wiki Documentation of ROS on new patient

[mrolf]

We have a specialist that works out of our family practice clinic and using the same chart as the FP physicians. Specialist sees a patient for the first time and documents in his dictation that he reviewed the PFSH & medications that is on the face sheet in the front of the chart. Is this acceptable for an audit. Another scenario is where the specialist has the patient fill out questionaire which included the PFSH, medications, and ROS. Can the specialist state in his documentation that he "reviewed the PFSH, medications, and ROS" and this would be acceptable? The patient marks yes in the box related to the ortho part and either leaves the rest blank or marks no. I don't feel real comfortable with this, although sometimes he does mention the positive in the SOAP note but does not mention "all other ROS negative". Would this be acceptable for a complete ROS without the statement all others negatave. If someone could give me some answers on this so I can approach the specialist on this subject, it would be helpful. Thanks.

 

[Peter Davidyock]

simply stating "all other ROS negetive" will not withstand an audit.
The specialist needs only document that the PSFH and medications were reviewed.
He does not have to repeat/reproduce them.

 

[FTessaBartels]

Ros & pfsh

ROS and PFSH can be completed by anyone. However, in order to get credit, the physician MUST state that s/he reviewed the material and the location of that material. For example: ROS & PFSH from patient questionaire dated mm/dd/yy reviewed by me today and no changes noted..

Hope that helps.

F Tessa Bartels, CPC, CEMC