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LTibbetts

LTibbetts

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I know that I have probably asked this before but I need some more information and back-up on this again.

A hospital ER that uses only t-sheets for documentation and nothing else (no other dictation):
Under the ROS section is a box labeled "all systems negative except as marked". What are we supposed to do if the doc only checks this box and nothing else in the entire ROS section?
 
I know, and that's what I thought, too, but I listened to a webinar yesterday that says it may be ok in some cases, but if an auditor came and saw over 100 charts like, that it wouldn't look so good, so I was kind of hoping to get something a little more definite or something in writing, you know? The webinar also said that in order to check that box, you have to have a positive pertinent or negative finding for at least 4 other systems before you can check that box to use it properly. What if there isn't even a slashmark through any of the other systems, let alone any positive/negative findings? What would you do in that case? I guess the rules vary depending on who you talk to. I have been over and over the DG's, but they don't really clarify this particular issue with that darn checkbox. They are very vague about it. Even on the webpage you posted it states that "for the remaining systems, the notation is permissable". If nothing is checked, there is no remaining anything, right?
 
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