decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 12 (December)
Put practical application of ROS “shortcuts” to work
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Article Overview
This article discusses how review of systems documentation shortcuts are applied in evaluation and management recordkeeping. It focuses on when prior patient-entered history information may be referenced, how documentation should reflect earlier information, and the clinical situations where these approaches are most relevant. It is aimed at physicians, coders, auditors, and compliance staff who work with E/M documentation standards.
Why This Topic Matters
Understanding these documentation practices helps support accurate evaluation and management history reporting and consistent provider recordkeeping. It is especially relevant for groups managing reused patient history forms, comprehensive histories, and compliance-oriented documentation workflows.
Article Sections
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Question and answer on dated health history questionnaires
Introduces a documentation question about patient-completed history forms and how they relate to office visit records. The discussion centers on how prior information may be referenced in a current encounter.
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Review of systems documentation guidelines
Summarizes guidance from the evaluation and management documentation rules regarding review of systems and past history information. It outlines the general framework for using previously obtained history in later encounters.
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Additional ROS shortcuts and practical application
Describes other broad documentation shortcuts and explains when they are most useful in practice. The section ties these concepts to common visit types and documentation needs.
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Resources
Provides a reference to the related documentation guidance source used in the article.
What You Will Learn
- How review of systems documentation shortcuts fit into E/M history requirements
- When prior patient history information may be referenced in later visits
- Which general visit types commonly involve comprehensive history documentation
- How documentation workflows intersect with compliance review
Who Should Read This
- Physicians
- Medical coders
- Medical billers
- Compliance staff
- Practice managers
- Auditors
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