Wiki ROS - Question

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LLRodgers

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Hello,

Just need some direction.

If a physician documents - Review of systems is as mentioned but has not dated and initialed the ROS Form can what he dictated be used?

The patient filled it in on the intake sheet but the physician did not date and initial it.

Any help is very much appreciated.

LLR
 
Short answer, no

It's common for patients to be given a ROS form to fill out. However, if the physician has not initialed it with the date (and even better the time as well) then no, this cannot be used for documentation. There is no way to show that the physician actually reviewed it. Same for EKG and labs.

And according to the 1997 E/M documentation guidelines, if this form is used for visits after the initial visit, the physician needs to document the date and location of the initial ROS form that is being referred to (page 6).

Problem that this creates:

So the patient is roomed and the MA comes into the room and asks the patient about every single ROS there is, because a COMP ROS was done initially, so the MA just repeats everything or follows the ROS in the computer. So every patient always has a COMPLETE ROS on every visit. When auditors see this, they ignore the ROS since you can tell that it was not done specifically for the patient being treated.

This is all too common and if a COMP ROS is done on every patient, use MDM for the E/M level.
 
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