Review Of Systems Documentation Example

She is a prediabetic.

Review of systems documentation example. In theory the ros may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention. The review of systems is distinct. This month yo info will focus on one piece of the e m puzzle the review of systems. Full review of systems constitutional.

The review of systems ros was the most frustrating aspect of charting as an intern. Review of systems ros. No history of nasal trauma. If you review all the systems with the patient and document the pertinent positives and negatives you may use statements such as complete.

Per the 1995 medicare documentation guidelines 10 systems including pertinent positives and negatives constitute a complete review of systems which is required for level 5 99285 visits. No hearing changes no ear pain no nasal congestion no sinus pain no hoarseness no sore throat no rhinorrhea no swallowing difficulty. He is hard of hearing. The patient denies any nausea vomiting headache diarrhea constipation fits pains or seizures.

No weight change no fever no chills no night sweats no fatigue no malaise ent mouth. No pleuritic chest discomfort. No new headache hearing or visual problems. But if the documentation specifies the patient states that she has a sore throat.

No nasal sinus congestion. E m documentation involves three components. The review of systems ros is an inventory of specific body systems performed by the physician in the process of taking a history from the patient. No weight change change in appetite thirst.

For efficiency many of us include any pertinent positives and negatives in the history of present illness hpi and use an ros caveat such as 10 14. The ros is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. Gastrointestinal review of systems is negative. She has no history of lung disease.

Ophthalmology practices can use both e m and eye codes but each has its own documentation requirements. For example if the documentation read the patient states she has a sore throat credit would not be given to both the hpi location and to the review of the ent system. She does admit to generalized weakness and poor appetite and also impaired memory. No history of hypothyroidism.

No history of coronary artery disease congestive heart failure or cardiac dysrhythmia. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. The history component entails three parts.