Melissa Posted Wed 13th of March, 2013 11:41:25 AM
can a doctor put ROS as noted in HPI? or does he have to complete the ROS this is an established pt?
SuperCoder Answered Wed 13th of March, 2013 13:14:15 PM
Yes, he can. Sometimes physicians write detailed info within HPI, which includes all components of History. A coder needs to understand reading the documents which all points could lead toward ROS (points that indicate words from Pt.'s mouth). There is no necessity to complete a separate section of ROS. There is no difference of rule whether it's New or Est. Pt.
E.g., HPI says --> "The Pt. came for a F/U of his left shoulder pain which currently has improved."
Here within this single sentence, you find CC - "F/U of his left shoulder pain"
HPI: Location - Shoulder ; Quality - Improved.
ROS: Pain in Musculoskeletal system
Melissa Posted Wed 13th of March, 2013 14:23:14 PM
but your example says ROS: pain in musculoskeletal system. His states ROS as noted in HPI. So yes he can just put a statement in the ROS stating ROS in HPI?
SuperCoder Answered Wed 13th of March, 2013 15:25:42 PM
Some doctors do that, some do not. Irrespective of that statement mentioned (if mentioned, then really good), you can consider ROS point(s) from HPI section. A lot of times, HPI consists of long paragraph, which is then filtered by coders to find out separate points for separate sections.
Melissa Posted Wed 13th of March, 2013 16:22:26 PM
ok then the answer is yes he can put ROS as noted in HPI that acceptable but it would be better if he did?
SuperCoder Answered Thu 14th of March, 2013 14:57:07 PM
Correct. Clear documentation always attracts less chance of getting heavily audited.