Documentation: Answer These Questions, Receive a ROS Refresher

Why This Topic Matters

Understanding ROS is important for accurate ED documentation and history leveling. This refresher helps readers recognize the general structure of ROS and the documentation approach expected in E/M encounters.

Article Sections

1. Question 1: How do we determine which elements are included in the ROS?

   Introduces the review of systems and summarizes the broad categories of body systems used in ED documentation. It also explains the role of ROS within the patient history.

2. Question 2: Which ROS levels apply to E/M services?

   Reviews the general levels of ROS used in evaluation and management encounters and discusses how they relate to documentation depth. The section also references ED visit levels and history classification.

3. Question 3: Which questions are valid to ask the patient to determine the ROS?

   Focuses on the style of questioning used during ROS documentation and the importance of directly addressing each system. It contrasts broad and more targeted questioning approaches.