Wiki NO ROS in HPI sections

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JLM929

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I am having a brain fart with Ros section. If a provider documents that ROS is unobtainable that marks the level down to problem focused in the HPI section. Is there anything special that could be documented to increase the level or would it be a level 1? Please help :confused:
 
Does the provider indicate why the ROS were unobtainable? The ROS can also be documented by the nursing staff, taken from the HPI, and findings from the past medical history such as HTN or DM.

I hope this helps.

Kelly M. Titus, CPC, CPC-I, CEHRS
 
He did not mention why it was obtainable. I did find another scenerio "difficult to obtain ROS the patient is lathargic, there is no report of chest pain or abdominal pain as stated. he did have respitory failure and is now off ventilator he has foley catheter in place. Dysphagia." Can we use 4 systems for this one?
 
Yes, I would say that phrase counts as 4. I always tell providers to avoid saying it is "difficult to obtain ROS." What they should do is:
A) If the patient will answer, document what you can
B) If the patient cannot give you ROS, document why you can't obtain it
C) If the patient is able to give you just a few answers, document what you could get, then document why you were unable to get anything else

Example: "Patient is very lathargic today. His breathing is a little better, he is off the ventilator. Foley catheter is in place. He did not have any chest pain or abdominal pain. Unable to obtain any further ROS as the patient was quite somnolent."

Something like that - it shows that you tried to get some info, but really couldn't get much, and explains why.
 
ROS can be obtained from others

And remember, that the ROS can be obtained from others ... the parents, children, spouse, nursing staff, EMS, etc

Just because the patient is unable to provide ROS (in my mother's case because she has advanced Alzheimers and is nonverbal) doesn't mean that no ROS can be obtained.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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