Wiki ROS

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jhaider

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Would you code this ROS as Detailed (2-9) or Comprehensive (10+ systems)?

''Denies any fevers, chills, N/V/D, abdominal pain, and urinary symptoms. Patient seen and examined. Denies other complaints at this time."

I'm having a friendly disagreement with a Resident, MD for an inpatient consultation. Please give me some advise :)

I was always taught to use this verbiage, " All other systems were reviewed and are negative"
 
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Your right. This is not "Comprehensive". We can see what s/he is trying to do, but they did not do it. The physician needs to document all positive & negative ROS, and then state "All other systems reviewed and are clinically negative". This documentation just says "Denies other complaints at this time". That may or may not have anything to do with ROS. Physicians always try this short cut, and almost never get it correct.
 
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Orthocoderpgu said:
Your right. This is not "Comprehensive". We can see what s/he is trying to do, but they did not do it. The physician needs to document all positive & negative ROS, and then state "All other systems reviewed and are clinically negative". This documentation just says "Denies other complaints at this time". That may or may not have anything to do with ROS. Physicians always try this short cut, and almost never get it correct.
Click to expand...

THANK YOU!!!
Sometimes I second guess myself but I just needed extra clarification from another coder to show him.
 
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jhaider said:
Would you code this ROS as Detailed (2-9) or Comprehensive (10+ systems)?

''Denies any fevers, chills, N/V/D, abdominal pain, and urinary symptoms. Patient seen and examined. Denies other complaints at this time."

I'm having a friendly disagreement with a Resident, MD for an inpatient consultation. Please give me some advise :)

I was always taught to use this verbiage, " All other systems were reviewed and are negative"
Click to expand...
Now I have a question for you. You used the word "Consultation". Was the three "R"s of consultation met?
 
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