Wiki ROS Documentation

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Kreismann

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I would like to know if documenting ROS as GI-negative, Eyes- positive is acceptable, or do I need to say what is negative, and what is positive?

Thank you
 
You can say "eyes" = negative but when something is Positive it should actually state what the positive is or it is pretty much useless.
 
the provider or staff that completed the ROS must expound on any positive findings per the DG. The provider is responsible to review any ROS doc done by office staff and make corrections where needed.
 
From the 1995/1997 guidelines: "Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible." So, yes, the provider should document all of the positives and 'pertinent' negatives, but as long as they have done that, the other systems can be counted as having been reviewed with just a statement of 'negative'. And agree with the above, provider must review with the patient if the staff has completed the form.

Thomas Field, CPC, CEMC
 
Thank you all. this was helpful.
Would the following documentation be acceptable:
GI- "reviewed and normal "
Pulmonary - "reviewed and normal "
 
Review of Systems

As far as CMS goes in the E&M Services Guide they say that when documenting pertinent positive/negative results they expect detail. On those systems that are not pertinent to the condition the patient is being seen for can be listed as just positive or negative.
 
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