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Avoid Common Misktakes When Documenting Review of Systems

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Avoid Common Misktakes When Documenting Review of Systems Coding Checklist Avoid Common Misktakes When Documenting Review of Systems Some clinicians confuse the ROS with History of Present Illness and Past Medical History. By Sharon Andrews, RN, CCS-P his column recently reviewed the importance Review of Systems: This inventory of body of accurately documenting the Complaint or systems is obtained through a series of questions “The Why” of the patient visit (August 2010, seeking to identify signs and/or symptoms that Tavailable online at PracticalDermatology.com). the patient may be experiencing or has experi- This has been an area of ongoing confusion for enced in association with the current complaint. practices, where there is a tendency to inappropri- Generally, the Past Medical History will be ately note what the provider did (such as “check comprised of known diagnoses, while the Review left leg”), rather than appropriately indicate the of Systems will consists of signs and symptoms medical necessity (such as, “f/u rash, left leg”) for related to the complaint that will support the the service. Another area of confusion for many provider in arriving at a diagnosis. The key differ- practices is documentation of the Review of ence between Past Medical History and Review Systems (ROS), which is the source of many ques- of Systems is that the ROS identifies signs and tions submitted to us online via our support serv- symptoms, not known diagnoses. ice DermAnswers (DermResources.com). The HPI and the ROS may overlap. For exam- Overall, there seems to be confusion between ple, a teaching document by Dr. Richard Rathe elements of History of Present Illness (HPI), Past of the University of Florida gives the following Medical History (PMH), and Review of Systems examples of ROS for the integumentary system: (ROS), each of which is described below. Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail History of Present Illness: Specific to a particu- changes. Many of these could also be documented lar complaint, it includes location, duration, modi- as signs and symptoms under History of Present fying factors, quality, timing, context, severity, and Illness. signs and symptoms. Importantly, systems other than the integumen- tary might be reviewed during a dermatology visit, Past Medical History: This is comprised of the such as asking a patient who presents with patient's past experiences with illnesses, opera- urticaria if he/she ever has trouble breathing (res- tions, injuries and treatments. piratory). Other systems will be reviewed but may not have anything to do with the HPI. For exam- Quick Tip: Generally, the Past Medical History will be ple, if you consider prescribing an antibiotic by comprised of known diagnoses, while the Review of Systems mouth, you may ask the patient, “Do you get nau- will consists of signs and symptoms related to the complaint sea from taking antibiotics by mouth?” (GI) or “Do that will support the provider in arriving at a diagnosis. you get vaginal irritation when taking antibiotics by mouth?” (GU). ■ June 2011 | Practical Dermatology | 39.
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