Wiki Incomplete Documentation of ROS

[kimberlydegrazia]

"Past medical history, medications, allergies, social history, family history and review of systems the same as my note from 2/5/13". Is this acceptable documentation for a Level 4 established patient? Please help, thank you.

 

[Pam Warren]

What's preferable is that they say PFSH "was reviewed with the patient today, and there are no changes from my documentation on 2/5/13". If I was having a good day, and there was chocolate in the office, I would probably let this go, with advice to the provider to indicate the next time that he document that he did a re-review all of the PFSH.

 

[kimberlydegrazia]

Hi Pam,

You're funny, chocolate always helps
For the ROS, shouldn't he provide documentation for at least 2? Then maybe state the rest of the ROS is negative, if it is?

 

[Pam Warren]

I wouldn't count a review of a previous note....the ROS should pertain to today's visit. ROS should be relevant to the chief complaint, so pull forward information is not advised. There can be a single system review, for a minor problem relative to that system, but it should relate to why the patient's there. All others negative is appropriate only if it's medically necessary to review all the systems...not just to ramp up the HPI.

 

[shruthi]

As per Medicare learning network - E&M service guide,

A ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded
if there is evidence that the physician reviewed and updated the previous
information. This may occur when a physician updates his or her own record or in an
institutional setting or group practice where many physicians use a common record.
The review and update may be documented by:
• Describing any new ROS and/or PFSH information or noting there has been
no change in the information; and
• Noting the date and location of the earlier ROS and/or PFSH.

Hope this helps.

 

[mitchellde]

the Key is noting the date AND location of the previous note. Almost no physicisan does this, it would have to state... "from my office note of .........." It has to be clear which note and where it can be found and that it was reviewed with the patient.