Wiki Review of Systems statement

[lrosselli]

A provider documented five Review of Systems (documented in the HPI) and then made the following statement in the Review of Systems section of the report: "Other than mentioned in the HPI, he has no other symptoms". Does this statement satisfy the requirements for a Complete Review of Systems? I'm not so sure an auditor would accept it. Thank you!

 

[LLovett]

No, this does not meet the requirements.

Guidelines state either 10 systems documented or document pertinent postive and negatives with a statment of all other systems negative. Some carriers won't even accept the all others negative verbiage anymore.

The statement of no other symptoms could just be referring to the systems he already reviewed or could be based on a general question of "anything else wrong?".

As an auditor I would not accept it.

Laura, CPC, CPMA, CEMC

 

[hewitt]

I agree, and by the way, well stated! I am an auditor, and would not accept it either.

 

[lrosselli]

Thanks Laura!