PE: Leave out ROS? 3 pertient findings?

[qqw]

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I'm using Dr. Kauffman's PE book...and he does NOT separate a review of systems section in his interview or SOAP note... Can we just ask the ROS under associated symptoms in HPI? Or must we make the ROS distinction?


Also, do we need to ask and document 3 pertinent findings for each Past medical history, past surgical history...

or can we just ask "Any surgeries?" and document it as : Past surgical history: None.


Thanks... Exam creepin up...Sweatin' over here :/

 

[EmergDoc2B]

I asked specific ros q's and listed them right under HPI / OPPQRST as admit to and denies. Then jumped into PMFSH.
hope this helps.

 

[cabergoline2]

you need not have a distinction between ros and pmh...but having one makes it seem more organized ...