tci ED Coding & Reimbursement Alert - 2004 Issue 9

READER QUESTIONS: Get Doctor's Review for History Elements

Question: Can we use nurses' notes to satisfy elements of ROS and PFSH, as long as the physician documents his review of the notes?Minnesota Subscriber Answer: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for review of systems (ROS) and past/family/social history (PFSH) with information from the nurse's notes. You'll use ROS and PFSH, along with the patient's history of present illness (HPI), to decide how much information the physician gathered about the patient's history.The review of systems is basically an inventory of the body...

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