Wiki Double-Dipping Questions

[kewing]

I have seen many times that the chief complaint cannot be counted as an element in the ROS. For example:

CC: Cough
ROS: Cough (resp), no headache (neuro)

For this type of documentation, there would only be one element present in the ROS, as I understand it.

Can anyone point me to an authoritative reference supporting this? I can find many references regarding the use of a single statement for HPI and ROS, but not for using the CC in the ROS.

I also would appreciate an authoritative source regarding the use of the statement "no known allergies" as ROS and past history. My understanding is that this is not allowed, but again, I do not have a reference.

Thanks much!

Karen

 

[krotroff]

I use 'no known allergies" in PMH, unless eparately stated for ROS I don't think you can use it as both PMH and ROS. THe CC can be used in the HPI, HPI elements can be used in the ROS, so by the transitive property it can be used in ROS, maybe? I don't have an authoritative source for that but the argument could be made. However, there should be more documentation besides just "cough" anyway, I would hope.

 

[kewing]

Thanks krotoff for your reply. Is anyone else aware of any authoritative resources to which I can refer for back-up on any of this?

Thanks.
Karen