Ros

Hello all-

I am reviewing new patient/consult notes for our docs and one of the docs for his ROS states...


She offered no focal complaints. Bowel and Bladder habits are normal.

My question is, we have EMR (electronic medical record) and I was wondering if I was able to refer back to the seperate ROS/History that the NP takes prior to the doctor going in or does the doctor have to make a statement to refer to the EMR in his note before we can refer to it?

Thanks : )

Ros

In order to count a ROS taken by a staff member, or completed on a history form, there must be evidence that the physician reviewed it.

From the article in Codapedia on ROS:

A staff member may complete the review of systems or the patient may complete this ROS on a form, and it can count towards the level of service for the note, as long as there is evidence that the billing clinician has reviewed this information. This might be shown by the billing clinician reviewing the form, making comments, and signing and dating the form. Or, the clinician should add to the documentation “the remainder of the review of system is on the history and was reviewed with the patient by me.”