Wiki ROS

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No, not for established patients. ROS is one of three components of the history.
For new patients, you must document all 3 components of history; for established patients, 2 of 3.
History components:
  • History of present illness
  • Review of systems
  • Past medical, family & social history
 
I do not see anything that states it can be skipped entirely (an old one can be used if referenced by date), but I am still new at this. Here are some links, and I can refer back to course material this weekend:

" ● You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI. ● You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. You may document the review and update by: • Describing any new ROS and/or PFSH information or noting there is no change in the information. • Noting the date and location of the earlier ROS and/or PFSH. ● Ancillary staff may record the HPI, ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information. ● If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history "




"E/M University Coding Tip: You DO NOT need to re-record a ROS if there is an earlier version available on the chart. It is acceptable to review the old ROS and note any changes. In order to use this shortcut, you must note the date and location of the previous ROS and comment on any changes in the body of the current note. For example, if you are seeing an established patient in the office you can say: “Complete ROS which was performed during a previous encounter was re-examined and reviewed with the patient. There is nothing new to add today. For details, please refer to my previous note in this chart, dated 11/23/2004.”

 
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