Wiki ROS/PFSH question

Create Wiki
AmandaW

AmandaW

Guru
Messages
249
Location
Jacksonville, AR
Best answers
0
Is it acceptable for the ROS to state:

"All thirteen systems reviewed; shortness of breath on minimal exertion."

"All thirteen systems reviewed; as mentioned above."

"All thirteen systems reviewed; no major abnormaility."

I'm auditing an Oncology Dr and have never seen it documented in that way. Does it have to state "all others are negative" or is that implied?
_________________________________________________________________

Regarding the PFSH, does saying...Social: reviewed and no changes since previous visit ok?
 
ROS question:
Those systems with positive or pertinent negative responses must be individually documented.

PFSH question:
It is acceptable to review the old PFSH and note any changes. In order to use this shortcut, you must note the date and location of the previous PFSH and comment on any changes in the information since the original PFSH was recorded.
 
Ok, so those ROS wouldn't be acceptable since they didn't state the negatives or use the wording "all others negative"?

And I guess they can't just state previous visit or last visit? Although that would be easily referable to the auditor I would think-just simply go to their last visit. But, ok, it does have to have the specific date...?
 
That's correct for both. On the PFSH it does have to have the specific date. They can't say something like "last visit" or "visit 2 weeks ago". When I first started, I had a physician reference "a visit 2 weeks ago". I could have easily pulled visit from 2 weeks ago but per the guidelines they have to be very specific.
 
You must log in or register to reply here.
Top