Wiki Ros completed by patient

[MEDCODING]

While reviewing a chart I came across a ROS that was completed by the patient. The form says "Review of Systems Do you have any of the following complaints or symptoms at the current time? Check where applicable"

The bottom of the form says "Personally reviewed, the rest of the ROS unremarkable. MD initials_____"

I've not seen an ROS completed in this way before. Usually I find patient history forms completed in this manner. It was my understanding the ROS needed to be completed by the physician. Would you count this if you were auditing this chart?

Any info is appreciated.

 

[mitchellde]

the patient can fill out the ROS since this is history and not exam, however the provider must document that it was reviewed with the patient and then remark on the pertinent positive and negative issues.

 

[MikeEnos]

I think you may be slightly confused - the HPI has to be completed by the physician. The ROS and PFSH can be obtained by ancillary staff or provided by the patient on a form like this... as long as the provider documents that they reviewed it. I've seen forms like the one you described quite often, but often the provider forgets to date and initial them to indicate that they personally reviewed it. Without that signature, I don't give credit.