Wiki Ros

[CC5657]

One of our physicians documented a hospital note with this ROS:

"At present, the patient is encephalopathic and not able to follow any verbal commands. His children are at the bedside and history as well as review of systems were reviewed with them."

Now, I know that you can't do a ROS on anyone else but the patient, this being said, can I still give credit for a complete ROS, since he states that the patient is encephalopathic & not able to follow verbal commands?

 

[eadun2000]

Yes you can. I know one Medicare carrier says no, but all documentation and guidelines state that this perfectly acceptable as long as the physician documents why he cannot obtain the ROS, which your physician did.