Wiki Ros

[anggand@aol.com]

Patient is seen for a followup and the medical assistant documents 6 Ros however, she asked me today if she can document negative Ros also. I think she can but, I'm not sure if we can get credit for them. I read that at least 10 ros must be reviewed but she only reviewed 6 that were pertinent to the pt's problem and how would she document it. Would she list the 6 ros then say all others were negative? help im lost

 

[jdibble]

Yes she can document the negatives. Documentation of the ROS includes the pertinent positive and negative responses to the review of the systems. If all of the systems were reviewed the statement "all other systems reviewed and are negative" can be used (depending on your carrier or Medicare carrier - some MAC will not allow this blanket statement, so you might want to double check this with yours). If all systems have not been reviewed, documentation of the positive and negative responses of at least 10 systems would be needed for a complete ROS.

If the patient was in for a follow-up visit however, a complete ROS may not be medically needed.

Hope this helps!

 

[anggand@aol.com]

yes this helped alot thank you.......