Wiki Ros or exam

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asasands

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One of our surgeons did this consult and I am confused wether or not it can be counted for the ROS or Exam or both?

PMH: HTN, Breast Cancer
PSH: C-Section, Breast lumpectomy
NKDA
Meds: Lisinopril/HCTZ
Social: no tobacco, no ETOH, no drugs
USS: AFib
Gen: A+O x3 NAD
HEENT: NC/AE PERRLA TMI neck supple
Heart: RRR 5m
Lungs: CTA b/l
ABD: soft tender rlq
EXT: 5 edema
Neuro: CNII, intack
CT: + appendicitis

Plan: Pt will go to er roday with DR. REDD for Lap Appy poss laparotomy

Any help will be great
 
Response

That is History and Exam, but no ROS was mentioned. If he had stated at least 3 chronic diseases you could have skipped History and ROS and moved on to the Exam. But that looks like a level I consult.
 
HPI and Chief Complaint?

Where are the chief complaint and HPI?

Without those two basic elements, this is not codeable even to a level 1.

F Tessa Bartels, CPC, CEMC
 
There was a cc. Pain in lower abdomen 2 days ago, got worse at night. Low grade fever. Did not feel like eating.

Can somebody help me on what key words I should be looking for with ROS?

Thanks
 
Rules to remember

First rule to remember .... if you do NOT have 4 elements of HPI you do NOT need to bother with PFSH at all (you can't count PFSH unless you have at least 4 elements of HPI - or status of 3 chronic conditions).

Second rule - if you DO have 4 elements of HPI (or status of 3 chronic conditions), you need at least 2 systems in ROS BEFORE counting any PFSH.

Okay you have:
cc. Pain in lower abdomen 2 days ago, got worse at night. Low grade fever. Did not feel like eating.
PMH: HTN, Breast Cancer
PSH: C-Section, Breast lumpectomy
NKDA
Meds: Lisinopril/HCTZ
Social: no tobacco, no ETOH, no drugs

cc: pain
HPI: Location - lower abdomen
Duration - 2 days
Timing or context - worse at night
Assoc signs - did not feel like eating

ROS: Const - low grade fever
Allergy/immunologic - NKDA

PFSH: PMH - c-section & breast lumpectomy
social history - no tobacco, etc

This gives you a detailed history. If he had included a family history you would have a comprehensive history.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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