Do I Put Childhood Symptoms on Review of Systems
ED Charting and Coding: Review of Systems
The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at to the lowest degree ten elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such every bit "10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Optics, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)" or "A consummate Review of Systems was obtained and is negative except equally stated in HPI."
This obviates documenting x or more dissever systems, only what if you're at a site where the coders won't accept a blanket phrase? Should you keep your lengthy HPI and so nautical chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and maybe even helpful?
CMS Definition & Requirements
The ROS is "an inventory of body systems obtained through a series of questions seeking to place signs and/or symptoms which the patient may exist experiencing or has experienced". CMS recognizes the following organ systems* for ROS (1995 E/One thousand Documentation Guidelines, PDF):
- Constitutional
- Optics
- Ears, Nose, Mouth, Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
*Organ systems: A complete ROS must document systems, not regions of the body. This is an of import distinction, e.g. Eyes and ENMT count separately, merely Head and HEENT don't count.
You can certificate 4 types of ROS, depending on how many of the possible 14 systems are reviewed:
| East/M Level | ROS Type | Systems Reviewed |
|---|---|---|
| I | None | 0 |
| II/III | Problem Pertinent | 1 |
| IV | Extended | 2-nine |
| V | Complete | 10+ |
Work Smarter, Not Harder: Resuscitating ROS
How do you brand this section useful?
- Offload pertinent positives and negatives from the HPI into ROS.
- Organize your history with HPI get-go, then ROS, and PFSH concluding (mimicking how CMS arranges the E/M guidelines) so you can certificate a concise HPI statement and move direct to ROS. This will make your charting efficient, yet effective and billable.
- Use the ROS equally a cognitive backstop. Equally a junior resident documenting ROS, I frequently realized I had forgotten certain history questions, did non accept plenty information to exclude an particular on my differential, or that something the patient said did not fit with the residual of the picture, prompting me to re-evaluate my differential.
- Have a quick, rehearsed gear up of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of jiff? Airsickness or diarrhea? Painful urination? Rashes? Joint hurting or swelling? Numbness or tingling? Changes in mood? Rut or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question prepare to your practice setting and specific patients.
Final Tips
- I detail– positive, negative, or normal– will suffice for each system.
- If you employ dot phrases or macros, have a 2-4 organisation ROS for well-nigh patients and a complete ROS for patients that will achieve E/Chiliad level 5. Consider too having a separate pediatric ROS.
- Always document at least 2 systems to prevent downcoding to an E/M level 2-iii.
- ROS can exist obtained by ancillary staff or by patient questionnaire, as long as the dr. reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: "I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient." Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
- A complete ROS can be a hybrid, list pertinent positives and negatives by system, and and so a notation indicating "All other systems are negative."
- Both caveats used in the introduction are valid examples per CMS. If yous give a number of systems in your caveat, you must list that number of systems afterward, then the second version is more straightforward.
Source: https://www.aliem.com/charting-coding-review-of-systems/