Wiki Inpt Hospital coding for physicians

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tlwhlw

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When reviewing the patient's documentation to code a hospital admit, if the physician doesn't complete an ROS, can the information be taken from the HPI? It seems like I've heard this somewhere before, but can't find any proof...help!?!?

Thank you!
 
ROS = Reply to a question

It really does not matter "where" on the note the information is documented however a word of caution. ROS is an answer to the physician's question. If you can find it on the note: count it but make sure that it is an answer to the physician's question. Usually doing I/P coding, the history becomes the weakest out of the three Key Components anyway since the physician's already know why the patient is being treated and the physicians usually ask just a couple of questions to make sure the patient's responding to the treatment plan. An exception to this would be patients who are not responding. I hope this helps.
 
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