Wiki documenting ROS

[Jkwiatek]

Hello out there..

I am newbie to the auditing world. Looking at real live charts I am seeing where my providers have a form scanned in chart that is labeled "medical history" it has all of the usual yes /no questions.

The chart note has no mention of the ROS... it is my understanding that there should be a note in the body that references the form?

 

[2picky68]

ROS form

Hello and Welcome,

If the provider wishes to use the information from the form than yes the provider needs to state in the note that they reviewed the ROS form that was completed by the patient. This form should have the date in which the patient completed it and the provider should reference that date as well in the event there are more than 1 ROS forms in the record. This creates a link between the visit note and a specific ROS form. Ideally the provider should review, sign and date the newly completed ROS form before it is scanned in.

Hope this helps.