tlewiscpc
Contributor
If a provider notates in the ROS "psych: stable" and then under the exam portion notates "psych: stable" would you give credit in both section?
Thanks.
Thanks.
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Wiki ROS vs Exam and Same Notation
- Thread starter tlewiscpc
- Start date
MikeEnos
Guest
Ideally they should be different, but generally speaking the ROS is information obtained from the patient. The objective findings noted in the exam are the provider's findings. They may match up, they may not.
It's entirely possible that the provider asks "Any mood swings, anxiety, trouble sleeping, or racing thoughts?" To which the patient replies "No." So the provider writes down "Psych: stable" in the ROS. On his exam, he/she may note that the patient is alert, responding appropriately, seems to speak well, shows good judgement, etc. So that may explain the "Psych: stable" note on the exam as well.
I wouldn't just arbitrarily decide that since he/she used the same verbage, it must be thrown out. I would however use it as an opportunity to talk to the provider about stating negative findings (no mood swings, no SI/HI) whenever possible.
It's entirely possible that the provider asks "Any mood swings, anxiety, trouble sleeping, or racing thoughts?" To which the patient replies "No." So the provider writes down "Psych: stable" in the ROS. On his exam, he/she may note that the patient is alert, responding appropriately, seems to speak well, shows good judgement, etc. So that may explain the "Psych: stable" note on the exam as well.
I wouldn't just arbitrarily decide that since he/she used the same verbage, it must be thrown out. I would however use it as an opportunity to talk to the provider about stating negative findings (no mood swings, no SI/HI) whenever possible.
tlewiscpc
Contributor
Thanks. Yes, we're counting them but I just wanted to get another opinion. Makes sense and I will mention it to the physician. Good teaching opportunity.
FTessaBartels
Guest
Meaning of "Stable"
I would try to convince the provider to stop using the word "stable" ... it means only "no change." So, "Psych: stable" could mean that the patient was psychotic with suicidal tendencies yesterday and is still psychotic with suicidal tendencies. (Or as one physician explained it to me, "A dead person is stable...")
Encourage the provide to indicate "normal" or "within normal limits" or "negative"
Hope that helps.
F Tessa Bartels, CPC, CEMC
I would try to convince the provider to stop using the word "stable" ... it means only "no change." So, "Psych: stable" could mean that the patient was psychotic with suicidal tendencies yesterday and is still psychotic with suicidal tendencies. (Or as one physician explained it to me, "A dead person is stable...")
Encourage the provide to indicate "normal" or "within normal limits" or "negative"
Hope that helps.
F Tessa Bartels, CPC, CEMC
MikeEnos
Guest
Yes! Another one I see sometimes is "baseline" .... it is often used in the context of "poor, but no worse than normal for this patient."