Complete Review of Systems

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Complete Review of Systems

Postby JBowyer » Thu Feb 23, 2017 9:47 pm

Good afternoon,
We are in a debate as to whether the statement below qualifies as a complete ROS.

"A complete review of systems was obtained, positive results are indicated in the history of present illness and past medical history. All other review of systems were negative."

The HPI reads as such, "This is a 48 y/o female who was directly admitted from the -- clinic to WH hospital for right upper extremity pain, redness and swelling consistent with cellulitis. She was also noted to have cellulitis of bilateral lower extremities. Following admission to the hospital she underwent a CT scan of the right upper extremity. Results reveal diffuse edematous changes suggesting edema or cellulitis as well as possible thrombophlebitis. A venous ultrasound was subsequently performed and results suggested that superficial thrombosis of the right basilic vein. As a result of the findings, the cardiovascular surgeons were asked to further evaluate. The patient has a history of multiple medical problems. She was recently discharged from St. X's on 2/13 after being diagnosed with sialoadentitis. She was also diagnosed with pancytopenia. While in the hospital at St. X, she was intubated and on mechanical ventilation for some time. The patient states that she has felt she has had a fever since being discharged from St. X. She ultimately went to the -- clinic urgent care for further evaluation."

In my opinion most of the HPI is history, and the fact that the ROS does not tell me which ones were performed is questionable. But this provider makes a "habit" with using this phrase.
JBowyer
 
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