Wiki ROS Statement

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mistygirl

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I am studying for the E/M certification and I am struggling with the ROS. I was told it is okay to list each system and put "not present" and list a possible condition. Example; Respiratory Not Present-crackling, wheezing, cough. Thank you
 
The guidelines say the ROS should list the positives and pertinent negatives, so 'not present' is a negative which would be acceptable. However, I'd caution that this sounds like exam documentation and not ROS, so I would take a closer look at this note before deciding. Remember that the ROS consists of questions asked to the patient about their symptoms whereas the exam is the provider's observations. Providers usually document the ROS as 'denies wheezing' or 'negative for cough' to record negative responses, but 'not present' sounds more like an observation. Also, 'crackling' is something a provider would try to hear on an exam, not something they would ask the patient about.
 
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