grindlemacie
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How long can a chart reference a ROS?
Example: Complete ROS taken from pt in April of 2008, pt was seen April of 2011. Dictation states Pt positive for weight loss, increased cholesterol and thyroid problems all other systems negative per ROS dated April 2008.
Can physician reference back to the 2008 ROS; is there any documentation that states diction CAN/CANNOT refer back?
Example: Complete ROS taken from pt in April of 2008, pt was seen April of 2011. Dictation states Pt positive for weight loss, increased cholesterol and thyroid problems all other systems negative per ROS dated April 2008.
Can physician reference back to the 2008 ROS; is there any documentation that states diction CAN/CANNOT refer back?