Wiki Review of Systems - unable to obtain

[skaur]

Does physician gets any points for ROS when they are unable to obtain for any reason and they do state in the documentation that "unable to obtaine due to intubated status". This mostly happens in the hospitals.
Thanks
Simi

 

[TonyaMichelle]

Unabel to obtain Review of Systems

If the patient or other source is unable to provide history, the medical record must describe the patient's condition or circumstance documenting the reason for the patient or other source not being able to provide ROS, PFSH and/or HPI.

To answer your question specifically for ROS, if there are no element documented for the ROS, it will be considered a problem focused ROS.

 

[j.monday7814]

if the physician cannot obtain an ROS or any other verbal information from the patient because they are intubated then you can count a full ROS as long as it documented why it cannot be obtained. however, if the patient is able to communicate with the physician the following day or a couple days later then the physician should document that in his note and obtain an ROS

 

[abhishekrane32@yahoo.com]

the physician should document the reason why ROS is unable to obtain? and a reason should be related to medical condition of patient such as patient is intubated, unconscious , he has dementia or any such condition where patient can not respond.In such circumstances full ROS can be considered.

if document states unable to obtain ROS due to language barrier or patient does not want to answer, in such circumstances DO NOT consider full ROS

AbhisheK Rane CPC

 

[cindyseyer]

We are searching for literature/guidelines where it states we are able to count a full ROS if a provider is unable to obtain due to patient inability--unconscious, intubated, etc. We have recently viewed AAPC webinar on Defending an Adverse Audit which tells us we cannot get credit for full ROS in this situation.
Has anyone found this rule (either way) stated anywhere by an authoritative source?
Thank you.