The following systems will be recognized as part of the ROS: constitutional symptoms (e.g., fever, weight loss, vital signs); eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrinological; hematologic/lymphatic; and allergic/immunologic.
The ROS can be reported and documented by the patient, nurse, or ancillary personnel, but the physician or nurse must sign off and date the form to indicate that he or she went over the information with the patient.
There are three types of ROS:
- Problem-pertinent ROS: Your documentation must show the patient’s positive responses and pertinent negatives for the system related to the problem identified in the HPI.
- Extended ROS: Your documentation must show the patient’s positive responses and pertinent negatives for two to nine systems related to the problem or problems identified in HPI.
- Complete ROS: Your documentation must show that at least 10 organ systems have been reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.
Past, Family, and Social History: The last section of the history is the past, family, and social history (PFSH). A past history includes past experiences with illnesses, operations, injuries, and treatments. The family history reviews medical events in a patient’s family, including diseases that may be hereditary or place a patient at risk. Recording a patient’s social history includes an age-appropriate review of past and current activities.
For a new patient, all three indicators of the PFSH will have to be notated, and—for an established patient or consultation only—two have to be met to get the highest level of the PFSH. If there is no change, documentation from a patient’s previous visit is acceptable to notate in the file as “no changes” since the last date the original PFSH was documented.
Understanding how to correctly document the patient’s history will put you on the right path in receiving the correct coding level for your visits. If you have questions about this matter, contact the ACR’s professional coding specialist Melesia Tillman, CCP, CPC at (404) 633-3777, ext. 820 or via e-mail at [email protected].
