Review of Systems.

[Debi]

Would this be acceptable for a ROS in a dictation.

Other than that stated above, there are no new general, HEENT,cardiac,pulmonary,GI,endocrine,neurologic, musculoskeletalm dermatologic, or psychiatric.

This is what a few provdiers are using. But I was thinking that the pertinent positives or negatives had to be spefied. For example "All systems are reviewed and found to be negative," or " Pertinent Problems noted in HPI, all other sytems are negative."

I am just having a hard time explaining why I believe this is incorrect. Can someone please help?

Thanks, Debi

 

[suzanberman]

I would have to see what the "stated above" included. Yes, you are right. All pertinent positives and negatives must be documented. Then others can be noted as normal (or applicable issues stated). The term "All other systems were reviewed and are negative" is acceptable for most payers. You would just want to check with your local payer.

I am assuming you truncated the sentence as it doesn't indicate what is "no" in the sentence. If the sentence finishes with "...symptoms or issues with the patient at this time" or something like that, then this denotes at least 10 systems and can be used toward a complete ROS.

 

[Debi]

Sorry I guess I should have included that. Here is an example.

**** is a 50y female who is seen today for evaluation of stress incontinence. Her main complaint today is leaking with coughing, sneezing, laughing or any type of strenuous activity. She is very active, especially in the summer, and finds that she leaks small amounts. She does not wear a pad because she finds them uncomfortable. Rather, she changes her underwear more often. She denies any urinary frequency, urgency, dysuria or hematuria. She has nocturia once a night. No urge incontinence complaints. She denies any bladder pain or frequent UTIs. Really, her only complaint today is leaking with any type of strain or strenuous activity. She is G1P1- vaginal delivery at age 19. No previous pelvic injury or surgery.