Forum - Questions & Answers
Documentation of ROS
Hi there,
I work with a multi-practice group. I audit and speak with providers regarding proper documentation. The question I get all the time is "why do I have to complete a separate ROS? Why can't I include it in the HPI"? I explain the reasoning to them but, I want to find out if there is an easier way to help my providers understand.
Thanks,
Donna
they can
There is no reason the elements can't be in HPI as long as they are the proper elements. Rationally, if it does not apply to the "Present Illness" then they shouldn't be in the HPI. So a visit for a sore throat should not include abnormal periods in the HPI. If you need a reference, I can get you something.
Documentation of ROS
The Guidelines allow you to document the HPI, ROS and PFSH in sections labeled as such or in the HPI.
From the Guidelines:
!DG: The CC, ROS and PFSH may be listed as separate elements of history, or they
may be included in the description of the history of the present illness.
http://www.codapedia.com/~article_302_.cfm