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Colleen Posted Wed 16th of February, 2011 18:24:40 PM

Is a review of systems required for a physical exam for either 1995 or 1997 guidelines?

Sandra Answered Wed 16th of February, 2011 19:42:37 PM

A ROS is not "required" in either, 95 or 97 guideline for a problem-oriented exam. However, with no system inventory (ROS), the Hx level is reduced to problem-focused (PF) -->> a level 2 Hx, even if any part of PFSH is pertinent to the presenting problem.

One thing though - It is really unsual to not be able to find at least 1 ROS Q&A in the HPI, which does not have to be documented separately. But depending on the reason for the visit, perhaps a PF Hx is all that is needed in order to diagnose and treat the patient that day.

No matter - One should expect amount of Hx and/or Exam to be commensurate with the nature of the presenting problem / the level of medical decision-making (MDM).

If I assume by "physical", you mean a Preventive Medicine Service, then the Hx and Physical (H&P) needs only to be age/gender-based.

There are many ifs, ands, and buts, in both of the clincial scenario above, and therefore, this reply is should not be considered "all-inclusive".

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