Returning to our earlier example of the patient with documented chest pain with dyspnea, you may count dyspnea as both an associated sign/symptom for the HPI and for respiratory ROS (but you should not count “chest pain” for both cardiovascular and musculoskeletal systems in the ROS).
But (and this is a big “but”), if a patient shows up with only one complaint, you shouldn’t use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the physician dug deeper to find more information to assist him or her in identifying what is wrong with the patient and how to treat it (in other words, you should be sure that the physician truly did provide an ROS).
For example, if the patient presents with abdominal pain, and that’s all the physician documents, you shouldn’t report that single item in the history and ROS. But documentation of “abdominal pain, no nausea” means the physician asked additional questions beyond the presenting problem, which makes using the item in both the history and ROS acceptable.
Similarly, documentation of “cough” alone isn’t sufficient to count for both history and ROS; however, “cough one week, no expectoration, moderate shortness of breath” provides plenty of detail to support both the history and ROS elements.
