Wiki ROS intake form

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Griffith_Tiffany

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If a patient fills out this intake form (circles what symptoms they've had since their last visit) and the provider goes over the form and documents a complete ROS, does the intake form need to be kept on record, filed in the patients chart or can this be shredded since the provider has went over all pertinent review of systems? There seems to be some confusion on this.
Thank you in advance!
 
It should be kept in the record and if the provider reviews the sheet that the patient filled it, it should be initialed by the provider that he reviewed it. Since this form is taking the place of any ROS recorded during the face-to-face encounter, it should be kept as proof of documentation for any E/M billed.

I would also document in the chart note itself "Reviewed Patient ROS Form" or something like that.

Palmetto published this nice piece...

http://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Part%20B~EM%20Help%20Center~Weekly%20Tips~EM%20Weekly%20Tip%20Review%20of%20Systems%20and%20PastFamilySocial%20History%20Recorded%20by%20Patient
 
Even if the provider face to face performs a ROS and the form is just a quick " i see you have had X since our last visit"?


ellzeycoding said:
It should be kept in the record and if the provider reviews the sheet that the patient filled it, it should be initialed by the provider that he reviewed it. Since this form is taking the place of any ROS recorded during the face-to-face encounter, it should be kept as proof of documentation for any E/M billed.

I would also document in the chart note itself "Reviewed Patient ROS Form" or something like that.

Palmetto published this nice piece...

http://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Part%20B~EM%20Help%20Center~Weekly%20Tips~EM%20Weekly%20Tip%20Review%20of%20Systems%20and%20PastFamilySocial%20History%20Recorded%20by%20Patient
Click to expand...
 
Sorry, I missed a point in your original question... that the provider was goes over and records (again) a complete ROS in the chart.

If the doctor re-records the exact same ROS items, then I guess you could probably get rid of the patient's version. But, if there is anything else on it pertinent to the E/M or demographics, then I'd keep it.

I'll go on to mention a point about duplication of effort and efficiency... (some of this may apply)

Either you're wasting the patient's time having them complete a form if the provider is going to just record or perform a complete ROS anyways.

Or, you are wasting the provider's time. You can be a little more efficient with the provider's time by having the patient complete it, and then having doctor review and initial the form and just notate the chart that it was reviewed (or anything pertinent to the chief complaint).

In today's day and age with all the extra work needing to be done for compliance, MACRA, MIPS, PQRS, efficiency is important. Wasted time = wasted revenue.
 
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