Wiki Review of Systems documentation requirements

[Donna Buchanan]

If anyone can please share thoughts on this I would appreciate it. There is a great deal of controversy as to if a provider can use the phrase "Negative except as mentioned in PHI". When a provider uses this phrase can it be counted as a complete ROS or not? Thank you for your input!

 

[mgutirob]

ROS documentation requirements


A practitioner is expected to document all positive and pertinent and negative responses to some systems and may include a phrase "all other systems negative" when documenting a comprehensive or complete ROS. The practitioner must actually review all systems for this statement to apply.

DOCUMENTATION TIP:
Do not count elements previously counted and used in the HPI. If an element was used in the HPI, it cannot be used again in the ROS.

I hope that I was able to answer your question and provide you with clarity regarding documentation rules.

Sincerely,
Micky