Wiki ROS Blanket Statement

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mdwyer

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Our physician has been missing the ROS section and not having a lot of information in the HPI so they are now addending his record format so that they can just use the blanket statement below:

13 POINT REVIEW OF SYSTEMS: Reviewed and all negative.

Can this count for his ROS?

Thanks for your input!
 
No this is not sufficient for a complete ROS. He must state pertinent positives and negatives and he must state it was reviewed with the patient then he can state all others reviewed and reported negative, the ROS with each system reviewed must be in the medical record with the visit date and provider signature.
 
mdwyer said:
Our physician has been missing the ROS section and not having a lot of information in the HPI so they are now addending his record format so that they can just use the blanket statement below:

13 POINT REVIEW OF SYSTEMS: Reviewed and all negative.

Can this count for his ROS?

Thanks for your input!
Click to expand...

I agree with Debra, and want to add a couple of other points. If the ROS is negative, is there medical necessity for the visit? I can understand that if it is for a follow up type visit, and patient is stable, they might not have any complaints, but I wouldn't expect to see this on the majority of visits. Also, there are 14 systems. So by saying "13 systems reviewed", there is no indication of which 13 were reviewed. That is also a problem.

HTH!!
 
I also have a provider that is documenting "Specifically reviewed 11 systems and the only abnormality is...". I don't think that should be counted since I don't know what systems were reviewed, but I need some documentation somewhere that says that to prove to him that I need more. Any help would be greatly appreciated!
 
Should not be a template. It is not always necessary to do a complete review of systems. Should only review what is medically necessary.
 
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