Wiki Review of Systems

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Butterfly1972

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Hello, Please provide feed back for the ROS indication below. Thanks

Dr. A dictated the following in his ROS. "Wears glasses. No diplopia. No significant sinus congestion or nosebleeds. No dentures. No oral pain." My transcriptionists put all of this under HEENT. He wanted them to put it under EYES: NOSE: MOUTH: - so you would count it as 3 Systems instead of 1. I told him that everything he said was HEENT - not 3 different systems, and that dividing it under 3 headings would not make it count differently.
 
dmincey said:
Hello, Please provide feed back for the ROS indication below. Thanks

Dr. A dictated the following in his ROS. "Wears glasses. No diplopia. No significant sinus congestion or nosebleeds. No dentures. No oral pain." My transcriptionists put all of this under HEENT. He wanted them to put it under EYES: NOSE: MOUTH: - so you would count it as 3 Systems instead of 1. I told him that everything he said was HEENT - not 3 different systems, and that dividing it under 3 headings would not make it count differently.
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All the audit tools I've ever used didn't list "HEENT" as a category for ROS; rather it is listed out as "Eyes" and "Ears, Nose, Mouth, Throat". So technically, what he has documented would cover 2 categories. Regardless of how the transcriptionist typed it out, an auditor should recognize these separate systems, and be able to give credit in the categories appropriately.


Just my $0.02, hope this helps.
 
Whether it is transcribed as HEENT or Eyes; and Ear, Nose and Throat, it is counted as 2 systems under ROS.
 
Phyllis Bomberger said:
May I add a question to this. How do you explain to your Doctor the difference between ROS and EXAM. He states there are symptoms in the exam that cover ROS.
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And there should be at least some correlation between the ROS and Exam. The difference:

ROS is info given by the patient, often on a form they fill out before the provider goes in for the visit. This info can be taken by an MA/nurse, and either entered into the EMR as part of the visit, or if EMR is not being used, the paper form would be kept as part of the chart. Either way, the provider reviews the info in the ROS to get a "big picture" sense of what is going on with the patient. This is symptoms/problems that the patient is having, that may or may not directly relate to the reason for the appt.

The EXAM is what the provider observes/sees once he gets the HPI from the patient, reviews the ROS, vitals, PFSH, and any other info collected by the staff before he goes into the room...once he starts actually examing the patient.

Does this make sense?
 
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