ROS

Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the HPI. 

An example of unacceptable HPI documentation would be “I have reviewed the HPI and agree with above.”

ROS: 

• Ten systems are required for a complete ROS.

• Pertinent positives and negatives must be documented. 

• A notation of negative for the remaining ROS may be documented for the remaining systems. Some third-party payers may require documentation of 10 systems individually.

• The ROS may be documented by staff and/or the patient.

• The ROS must be reviewed by the physician, who must note that the information was reviewed. 

• The ROS may be separate from, or part of, the HPI. 

• One statement will not satisfy both the HPI and ROS components. 

Family and social history: 

• Past – events in the patient’s medical/surgery history 

• Family – diseases that may have an effect on the patient’s health 

• Social – age-appropriate environmental and social factors that affect the patient

Examination Component

For the examination component, all abnormal findings must be described. Normal findings can be indicated as a negative finding, but it is recommended that all negative and/or positive findings be documented. The allergy specialty has a specific exam as of 1997.  Most electronic medical records (or EMRs) incorporate the 1997 guidelinesintotheirsoftware for physicians to use. The 1997 examination guidelines are much more specific and indicate specific findings to be documented, whereas the 1995 guidelines are generalized per organ system and thus the provider must document specific findings.

The components for each system are listed here.

Organ Systems

• Constitutional
• Eyes
• Ear, nose and throat
• Cardiovascular
• Respiratory
• Lymphatic
• Gastrointestinal
• Integumentary
• Genitourinary
• Musculoskeletal
• Neurologic/psychiatric/ hematologic/immunologic

Body Areas 

• Head, including face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back
• Each extremity