How thorough of a ROS do you do?

[Pure Anergy]

I'm on an AI in EM right now. For most EM physicians I've worked with, they don't ask a complete ROS. But on my last shift, the attending made me go back and do a complete ROS on the patient. I was surprised since I wasn't ever asked to do that before on EM. No new information came up during the ROS, and at the time I thought it was overkill. But I was thinking later that I could see there being times when it would help catch something that could be missed otherwise.

So what I'm wondering is do you think it's necessary to do that thorough of a ROS? For some patients or all of them? If you do it for some patients but not all, do you base how many systems you review on how sick you think they are?

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[EM2BE]

I'm on an AI in EM right now. For most EM physicians I've worked with, they don't ask a complete ROS. But on my last shift, the attending made me go back and do a complete ROS on the patient. I was surprised since I wasn't ever asked to do that before on EM. No new information came up during the ROS, and at the time I thought it was overkill. But I was thinking later that I could see there being times when it would help catch something that could be missed otherwise.

So what I'm wondering is do you think it's necessary to do that thorough of a ROS? For some patients or all of them? If you do it for some patients but not all, do you base how many systems you review on how sick you think they are?

I found during my rotations this was attending dependent. I also found that for billing certain levels, you must have a certain number of ROS to qualify for that level. Perhaps this is why you were sent back or perhaps it was that if something was positive, it would have changed treatment.

 

[southerndoc]

I have my basics (fever, congestion, sore throat, chest pain, shortness of breath, cough, abdominal pain, nausea/vomiting/diarrhea, dysuria [discharge in a female], rash, headache) and then ask them if there is anything else I could've missed. I ask this on nearly every patient regardless of complaint. Of course I'm probably one of only a handful EP's in this country that listens to heart and lung sounds on someone with an abscess or a finger laceration.

 

[WilcoWorld]

The best ROS is one that is tailored to the patient's chief complaint, and one that will dovetail with the HPI. For instance - in abdominal pain the presence of fever, absence of constipation, presence of vaginal discharge, etc are all relevant. With chest pain it's a different set of things I want to know, with headache it's others still, and so on. As a student, it's tough to know what your attending will want, so a safe bet is to do a thorough ROS, incorporate what seems germane into the presentation, and then be ready to answer the rest of the questions should they come up.

Many times the ROS serves to get the chart to the best billing status. In this sense I'm pretty close to Southerndoc's practice with the acknowledgement that I will sometimes selectively ignore certain positives. For instance, I'm not going to do a chest pain work up (and thus I wont document "+CP" in the ROS) on someone who came in for a laceration and, only after being asked in the ROS, says something like, "Last month I had chest pain for a few seconds while I was watching America's Next Top Model. Isn't Tyra Banks great?"

My philosophy is that if you document something then you have to address it. Of course we must be honest, so I do not advocate lying on a chart, but I think that omitting something that is clearly irrelevant, was not a concern to the patient, and which addressing in the ED will incur significant expense and often risk (suppose that patient ends up with a contrast-enhanced CT) is an ethical choice.

 

[FoughtFyr]

I have my basics (fever, congestion, sore throat, chest pain, shortness of breath, cough, abdominal pain, nausea/vomiting/diarrhea, dysuria [discharge in a female], rash, headache) and then ask them if there is anything else I could've missed. I ask this on nearly every patient regardless of complaint. Of course I'm probably one of only a handful EP's in this country that listens to heart and lung sounds on someone with an abscess or a finger laceration.

I am almost exactly the same. My standard ROS (every patient) is fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abd pain, chest pain, SOB, DOE, palpitations, headache, syncope, dysuria, hematuria, and vag. discharge (in women). Then I ask if there is anything I missed.

And I listen to heart and lungs on EVERY patient.

To the OP - do you realize you can do a level 5 physical exam with just observation and a handshake...?

 

[deleted87716]

To the OP - do you realize you can do a level 5 physical exam with just observation and a handshake...?

What...? No need for even the "triple point?" 😉

 

[jllander]

I agree with all the posts above. Everyone gets the basic ROS, their heart and lungs listened to and their abdomen pushed on. I haven't even done this doctoring thing for a year yet, but I have learned the importance of getting into the habit of doing the same thing with every patient, because the first time you change your routine, you'll miss something important. On a side note, during my first month of intern year, I saw a patient on the night shift with heart palpitations. He was in his 30's so I wasn't hugely concerned. But being the new, scared intern that I was, I did a complete ROS. Low and behold, he was having myalgias, arthralgias, fatigue, headaches and had a circular rash on his leg about a month ago. A week later, his Lyme titers came back positive. Good thing I asked all that non-related stuff otherwise he would have gone home without being presumptively treated for Lyme disease. That case taught me a lot about the utility of a "screening" ROS.

 

[Pinner Doc]

But for every story like jllander's above, there is the patient who comes in with vaginal discharge, and during your ROS you ask if she is also having chest pain. She says, "Well, now that you mention it, doc..."

Now, are you obligated to get an EKG? A set of cardiac enzymes? Are you going to document that she said she had chest pain? Where do you stop? I've had attendings say to me, "It's not what she came in for, so don't work it up."

Somewhere on this spectrum is the old person with abdominal pain and constipation. Their abd pain is likely 2/2 constipation, but I'll still get the EKG, as abdominal pain is an anginal equivalent in many. But do you also get the troponin?

Sorry, waxing philosophical....

 

[Arcan57]

I toss weight loss into the mix, which leads to some stupefied looks on my patients with acute on chronic biscuit poisoning. If someone endorses a positive I'd rather not deal with, I'll often follow it up with "is it the same (pain, vomiting, bleeding from both eyes) that you usually have?" Today was chronic RUQ/flank pain day, and that helped avoid many unnecessary CTs and U/Ss.

 

[southerndoc]

Now, are you obligated to get an EKG? A set of cardiac enzymes? Are you going to document that she said she had chest pain? Where do you stop? I've had attendings say to me, "It's not what she came in for, so don't work it up."

If it sounds cardiac, then yes. We all have our infamous anecdotes, but I received a thank you letter from a patient who came in with leg cramps. I asked about chest pain and she told me yes over the past few months but her PMD had brushed it off as GERD. When I discussed about it further, she described it as exertional, had some shortness of breath, etc.

EKG had t-wave inversions and initial troponin was 0.9. Admitted, got a heart cath, and found to have triple vessel disease and went for a CABG at the young age of 41.

All because she came in due to leg cramps (her K was 2.9).

 

[Pure Anergy]

It seems like the consensus is to ask about constitutional symptoms, neuro (headache, syncope), heart, lungs, GI, GU. And then ask is there anything I missed. That's only half as many systems as the attending wanted, which probably means it's a realistic compromise.

 

[deleted109597]

Enough for a level 5 regardless of visit type (except for wound check/suture removal, since those don't bill). Remember, they can't upcode a poor H&P. They can downcode if they don't need it.

 

[Pinner Doc]

If it sounds cardiac, then yes. We all have our infamous anecdotes, but I received a thank you letter from a patient who came in with leg cramps. I asked about chest pain and she told me yes over the past few months but her PMD had brushed it off as GERD. When I discussed about it further, she described it as exertional, had some shortness of breath, etc.

EKG had t-wave inversions and initial troponin was 0.9. Admitted, got a heart cath, and found to have triple vessel disease and went for a CABG at the young age of 41.

All because she came in due to leg cramps (her K was 2.9).

Great job with the above. I still, two years into residency, grapple (sp?) with the ROS because of that one incident of being derided by the attending for getting an EKG on a woman with vag discharge who also endorsed CP on ROS. Implied I was doing unnecessary testing. That may be so. I guess this is something I'll fine tune as I get more clinical experience.

 

[GeneralVeers]

I like the "A total of 10 ROS were done, all are negative except as noted". That saves a lot of time, and lets you document a level 5.

 

[Soup]

I'm on an AI in EM right now. For most EM physicians I've worked with, they don't ask a complete ROS. But on my last shift, the attending made me go back and do a complete ROS on the patient. I was surprised since I wasn't ever asked to do that before on EM. No new information came up during the ROS, and at the time I thought it was overkill. But I was thinking later that I could see there being times when it would help catch something that could be missed otherwise.

So what I'm wondering is do you think it's necessary to do that thorough of a ROS? For some patients or all of them? If you do it for some patients but not all, do you base how many systems you review on how sick you think they are?

He may have just wanted you out of his hair for a little while.

 

[FoughtFyr]

What...? No need for even the "triple point?" 😉

Nope.

Play along.

General: Mr. X is a 30 year old caucasian male examined in the emergency department in bed number 7. He complains of general wimpyness and is in no apparent distress at the time of my exam.

V/S: (per triage vitals) (1 system done - Constitutional)

Eyes: Focus and track. Sclera non-injected, not icteric. (2 systems done - eyes, which are separate from ENT per CMS rules)

HENT: Normocephalic / atraumatic. Hearing is adequate to conversational voice, ears grossly without discharge. Nares patent and also without discharge. Face is symmetric and atraumatic. Mucous membranes appear moist. Patient able to handle his own secretions. (3 systems down - HENT)

Neck: Appears supple, patient freely moves normally. No gross tracheal deviation or JVD seen. (4 "systems" down - neck is a "body area" and can count)

Breathing: No obvious increased work of breathing, no respiratory distress. Patient capable of normal conversion without becoming short of breath. (5 systems down - lungs)

MS: Gait normal, upright carriage. No movement difficulties noted. (6 systems - MS)

Neuro: No gross focal neuro deficit noted. GCS 15. No seizure activity noted. (7 systems - neuro)

Psych: Patient alert and oriented times three. Mood, affect and interactions appropriate. (8 systems - psych)

Skin (here is where the handshake comes in): Normal color and temp (9 systems down - actually 8 systems and one body area, but hey, more than enough for a 99285)

A level 5 exam completed without anything other than a handshake!

Feel free to add any of the above to your template!

- H

 

[deleted87716]

I know you're kidding, but in the event somebody doesn't realize it, the reason that doesn't work IRL is that you can't make up your own bullet points. You have to use the ones that the coding guidelines specify. You're free to throw in extra stuff when it's clinically relevant, of course, but you won't get extra credit for doing so.

Sorry. It was funny, though. 🙂

 

[RxnMan]

...Neuro: No gross focal neuro deficit noted. GCS 15. No seizure activity noted. (7 systems - neuro)...

Facial expressions are full and symmetric.

 

[FoughtFyr]

I know you're kidding, but in the event somebody doesn't realize it, the reason that doesn't work IRL is that you can't make up your own bullet points. You have to use the ones that the coding guidelines specify. You're free to throw in extra stuff when it's clinically relevant, of course, but you won't get extra credit for doing so.

Sorry. It was funny, though. 🙂

Actually, while I'm not sure about in the office setting, in the ED that isn't true. What must be followed are the recognized system sub-headings (which I listed above as systems - the neck "body area" doesn't work at level 5 but would for a level 1 visit). There are suggested exam components, but none are required. There is a requirement that each system "exam" have at least two components to qualify.

That "exam" is from a talk I have given at two conferences for medical coders (the talk focuses on the disconnect between the CMS guidelines and the actual practice of medicine). It has been reviewed by several coders who all agree that in principle the exam would qualify as a 99285 as written, but state that ethically if the coder knew that the exam was being used to intentionally "up code" service it should not be submitted as such.

Which makes it far less funny...

- H

 

[deleted87716]

I've never used "body areas." It's not the way that doctors think.

Interesting article:
Top 10 E/M Coding Flaws http://www.fortherecordmag.com/archives/092809p22.shtml

 

[FoughtFyr]

I've never used "body areas." It's not the way that doctors think.

Interesting article:
Top 10 E/M Coding Flaws http://www.fortherecordmag.com/archives/092809p22.shtml

My shop is on the 1995 standard - so my example holds. But I agree with your article, the system (either 1995 or 1997) sucks. The beautiful part? A little publicized provision in the healthcare bill criminalizes billing errors!

- H

 

[Laryngophed]

What...? No need for even the "triple point?" 😉

I thought you were a Family Med doc, not an orthopedist? 😕

 

[deleted87716]

I thought you were a Family Med doc, not an orthopedist? 😕

I learned about the "triple point" on my general surgery rotation in med school. I don't think the orthopods even carry stethoscopes...

 

[Pure Anergy]

He may have just wanted you out of his hair for a little while.

That could be true. But considering that he made me go back and do it after sign-out was over and half an hour after my shift had ended, it's a little sadistic if he was only doing it because he could.

 

[Fletcher]

The true purpose of the review of systems is to review all systems to ensure you didn't miss anything major going on despite the relation to the chief complaint.

That being said I try to do a complete ROS on most people, but for the "ROS +" individuals I coach them a bit by repeatedly saying "I am looking for things that are not normal for you..." etc. It does get annoying sometimes, as it's almost as if they think you are looking for clues... If they aren't one of these types it usually takes a few moments.

 

[Arcan57]

The true purpose of the review of systems is to review all systems to ensure you didn't miss anything major going on despite the relation to the chief complaint.

And it's an valuable tool for medical students. It has its place in internal medicine. It is unfortunate that it has become a billing criteria for specialties for whom an exhaustive review of systems has no role. Should a medicine practice that has me fill out an entire page of check boxes get paid more than someone who in person asks me pertinent associated signs/symptoms related to my complaint?

Furthermore, I think a exhaustive review of systems may send the wrong message in some clinical settings, unless you plan on addressing every pertinent positive. Like the women who assume I've done a PAP smear because I did a pelvic exam for their d/c.

 

[Squad51]

The true purpose of the review of systems is to review all systems to ensure you didn't miss anything major going on despite the relation to the chief complaint.

That being said I try to do a complete ROS on most people, but for the "ROS +" individuals I coach them a bit by repeatedly saying "I am looking for things that are not normal for you..." etc. It does get annoying sometimes, as it's almost as if they think you are looking for clues... If they aren't one of these types it usually takes a few moments.

Fletcher,

As a medical student, that probably works for you. In an emergency department with more than 75,000 visits annually and where the the adage from the House of God (IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER) keeps you from beginning a chest pain work-up on the stubbed toe, you simply can't get that in depth with every patient.

 

[roja]

Medical students and even junior residents should do thorough ROS. They haven't seen as many patients and have little context to clue in to subtle things that might trigger a more experienced physician to ask focus ROS questions.

also, context is important. Admitted medical patients need a thorough ROS as they will be managing many problems, including nonacute issues as well as arranging post hospital management.

In clinic, most attendings don't take a full ROS.

As you are learning, you learn to focus your ROS based on complaint and the clinical gestalt.

 

[deleted65604]

On occasion I hate review of systems. The classic example is the cough/dyspnea in a young person that then complains of chest pain. You try to talk them out of it like, "But its very minor, right, just in your throat when you cough, right?" But they want to seem more sick and score narcotics, so they say, "No, doc, my chest is killing me!" Me: internal eye roll, and internal battle of "Do I order a d-dimer on this dope or not?"

I had this nightmare of a drug-seeker patient about 6 months back. She got struck by lightning a decade ago, with resultant compartment syndrom on an arm and chronically infected/non-healing wounds for years. Turned her into a savvy narc-seeker/addict. She came in by ambulance saying she was having seizures (straight out of that youtube video... I-am-having-seizures, I-need-xanax, I-am-anxious-that-you-are-not-going-to-give-me-xanax routine). On review of systems, she had abdominal pain, chest pain, neck pain, headache, and every once in a while she would start thrashing around in bed, arch her back up and start screaming in "pain".

I did the million dollar work-up, came up with nothing, and sent her home. Amazingly, she survived her partial seizures/ status-epilepticus/ pseudo-tetani and I've seen her a couple of times since for (infection in arm) requiring narcotic pain medication.

Those kind of patients, you don't venture into prompting with specific ROS questions. You chase down their 1-2 main complaints and do the work-up you know is going to be negative.

By the way, does anyone else hate the "Any vision changes question?" Invariably, people say "Yes, now that you mention it, I can't see good at all today." 90% of the time, you find out that they haven't seen an eye doctor in 4 years, and/or they aren't wearing their glasses/contacts. I've never had relevant contributing information gleaned from that question.

Doctors only do ROS for the most part to be able to bill appropriately for the level of care provided and not commit billing fraud. If you get audited by CMS and they find that 40 percent of your level 4 and 5 visits don't have adequate ROS, then they will assume that you have over-billed them for the past few years and now owe them 20% of what they have reimbursed you (hundreds of thousands of dollars). Your group could end up working for medicaid/medicare patients for free for a few years.

The randomness and arbitrary nature of government regulations lead to your bosses making you play documentation games to maximize billing, and not commit "billing fraud"

Ironically, the attempts by the government to avoid billing fraud actually lead to...well...fraud. Every one of my charts is required by my boss to have a complete ROS box marked on the T-sheet. Sometimes, I will get a chart 3 weeks later saying, "document complete ROS". As there is no way that I can possibly remember whether or not I asked these questions, I'm basically forced to lie.

 

[Jeff698]

Jarabacoa,

You just made the cardinal mistake of daring to utter the truth about ROS in EM. It is put there to force us to either lie, not get paid for our services or see 1 patient an hour.

I agree with Roja's point about inexperienced physicians. They should do the full meal deal because they're not quite sure yet what is relevant and what isn't. My heartburn, however, is about how these rules apply to attendings.

In EM, almost by definition, if something is relevant, it isn't in the ROS but in the HPI. Our focus in the ED is on their complaint as opposed to not-their-complaint.

I agree it's important in other clinical venues but I think it is forcing us to approach an H&P like clinic docs is missing the nature of our specialty.

Take care,
Jeff