It’s important to be sure that the level of the review of systems (ROS) makes sense when considered alongside the reason the patient is being seen and the time span from the last complete ROS. Why? Because auditors love to call question to multiple complete reviews of systems documented within a short time span. Repeated complete ROS within a month can make sense if the condition being managed changes for the worse or is complicated by a new problem, but a typical short-term progress evaluation won’t require a complete ROS.
As an example, a comprehensive examination that you’re performing on a new patient could easily justify a complete ROS whereas the 1-week follow up you perform on their dry eye status likely would not. In the latter scenario, the 3rd party auditor is provided the room to question the necessity of the level of ROS performed, whether the documentation truly represents what was performed, and other questions you shouldn’t need to take time out of your busy schedule to answer.
That being said, if you believe a complete review is relevant to the care of the patient on that day, you could very likely support your rationale if questioned in an audit. Our goal is not to say anything is definitely correct or incorrect, but rather to encourage consideration during the case history documentation.
