Forum - Questions & Answers

Jun 12th, 2009 - tbell49 3 

Auditing ROS in a pediatric visit

I was asked to audit a chart for an infant.. 3 months old. Seems to me I remember somewhere that the specs for the ROS is different for infants. How do I calculate the level for a new patient that is an infant?
thanks

Jun 12th, 2009 - Codapedia Editor 1,399 

Auditing ROS in a pediatric visit

From the 1995 Documentation Guidelines

For certain groups of patients, the recorded information may vary slightly from that described
here. Specifically, the medical records of infants, children, adolescents and pregnant women may
have additional or modified information recorded in each history and examination area.
As an example, newborn records may include under history of the present illness (HPI) the
details of mother's pregnancy and the infant's status at birth; social history will focus on family
structure; family history will focus on congenital anomalies and hereditary disorders in the
family. In addition, information on growth and development and/or nutrition will be recorded.
Although not specifically defined in these documentation guidelines, these patient group
variations on history and examination are appropriate.

You can find the place to download these from CMS in the citations from this article:

http://www.codapedia.com/~article_88_.cfm



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