Wiki HPI vs. ROS

[AKAJBART]

I just want to make sure I understand this correctly.

The ROS can be done by the MA, or other qualified office staff, correct? So the MA can drop the line that says "10 point ROS completed, and results are negative other than what is listed in the HPI".

However, the MA cannot complete the HPI, the Dr. has to do that portion, correct?

It just seems like the ROS and HPI go hand in hand, yet are being done at 2 separate times, by 2 separate professionals.

 

[mitchellde]

It is my interpretation that the MA cannot state all systems negative except what is stated in the HPI. That is the statement the provider can make after he reviews the ROS obtained by the MA. the provider must review the ROS and state that it has been reviewed, and in order to do that the systems must be listed with a response.

 

[AKAJBART]

Technically, we have a box that's checked in the EMR that states this. But the MA is supposed to still go over the ROS with the patient to make the documentation legal. We don't have a separate box to list any 'positive ROS'. The only place that the MA can add it, would be in the box that's marked CC/HPI that the Physician documents in.

But if the MA lists any documentation here, she'll need to leave her initials.

Would that be appropriate?

I absolutely hate the repetitious templates!!!

 

[mitchellde]

The physician is the one that goes over the ROS with the patient not the MA. The MA can collect the information as in ask the questions and record the answers or the patient can fill out the information from a questionnaire, but the physician is the one that must document that it was reviewed with the patient and note the positive and pertinent negative findings. This cannot be done by the MA.

 

[AKAJBART]

Thanks for your help, Debra. I appreciate it, and will check into how it's being done here. I'm new here, and from what I understand....... nobody has ever questioned how things are done here. Things are changing as long as I'm here.