Procedure

I am a new coder and when reading a report the doctor dictated he will put for the ROS

"As per separate medical summary sheet attached in the patient's chart and reviewed with the patient"

I have been pulling the patient's chart to verify that he did indeed date and initial the form.

My question: is what the doctor dictated enough or should I continue to pull the chart and check to see if dated and initialed by the doctor.

I am afraid that if ever audited could this become a problem.

Any help on this matter would be greatly appreciated.

Thank you,
Linda

re: Procedure

You should refer to the 1995 documentation guidelines. The guidelines state:

To document that the physician reviewed the information (ROS and PFSH) there must be a notation supplementing or confirming the information recorded by others.

A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.
The review or update may be documented by:
describing any new ROS and/or PFSH information or noting there has been no change in the information; AND
noting the date and location of the earlier ROS and/or PFSH.

These guidelines are available on the CMS website.

Louise