Tips to most efficiently achieve level 5 ROS/Exam documentation

[ERDude]

Wondering if others can share any tips they have to most efficiently achieve level 5 documentation specifically as it relates to ROS (10+ systems) and exam (8+ systems).

Not including "all other ROS negative" do you have catch-all questions (eg. 'any bleeding' and thus click negative for hematuria, rectal bleeding, epistaxis) that help you easily get to 10 ROS elements without asking each system individually (and not being fraudulent of course)?

Also anybody have a good no-touch exam that satisfies 8+ exam systems?

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[Angry Birds]

Head: Patient has a head.
Neck: Patient has a neck.
Resp: Patient is breathing.
Abdomen: patient has an abdomen.
Skin: patient has skin.
Neuro: patient is awake.

 

[JacobMcCandles]

There's something you can put down for every system just by looking.

 

[ERDude]

yeah fair enough exam is reasonably easy to obtain I suppose I'm more interested in tips to get the ROS elements done in a more efficient way without asking about every system individually.

 

[southerndoc]

This will be a moot point soon as the reduced documentation requirements by CMS go into effect.

 

[BoardingDoc]

This will be a moot point soon as the reduced documentation requirements by CMS go into effect.

I thought this is only going to apply to outpatient visits, not to the ED.

 

[BoardingDoc]

yeah fair enough exam is reasonably easy to obtain I suppose I'm more interested in tips to get the ROS elements done in a more efficient way without asking about every system individually.

Just click the all other systems negative box. If you are worried about being audited, just ask if they have any other fever, pain, bleeding or cough. Pain alone will get you 7 systems if you want to be technical.

 

[Angry Birds]

Just click the all other systems negative box. If you are worried about being audited, just ask if they have any other fever, pain, bleeding or cough. Pain alone will get you 7 systems if you want to be technical.

Yes, I just click on ROS negative.
I'm not worried about getting audited.
You gotta be a chump to go down that list and ask them one by one. I don't even put stuff positive unless it really is positive. Asking most of our patients a yes/no question makes them do something like this:

Physician: Do you have chest pain?
Patient: Hmmm...Now, that you mention it,yeah, I've had some on and off pain...

OK, now get ready to do a large unnecessary work-up if you chart that.
Don't be a chump. Just do an honest job of putting down what the patient ACTUALLY presents for, negative for everything else.

 

[southerndoc]

Just click the all other systems negative box. If you are worried about being audited, just ask if they have any other fever, pain, bleeding or cough. Pain alone will get you 7 systems if you want to be technical.

Not going to work soon. One of our major insurers no longer allows it, so we removed it from Epic.

 

[GeneralVeers]

Yes, I just click on ROS negative.
I'm not worried about getting audited.
You gotta be a chump to go down that list and ask them one by one. I don't even put stuff positive unless it really is positive. Asking most of our patients a yes/no question makes them do something like this:

Physician: Do you have chest pain?
Patient: Hmmm...Now, that you mention it,yeah, I've had some on and off pain...

OK, now get ready to do a large unnecessary work-up if you chart that.
Don't be a chump. Just do an honest job of putting down what the patient ACTUALLY presents for, negative for everything else.

Agreed. I'll take the hit under the lightning-strike possibility that I'm audited. Just click negative ROS. Probabably 30% of patients would have positive ROS, which if I documented what they told me they would get million-dollar-workups and admission.

 

[RoyBasch]

I don't know a single practicing staff ER physician who still legitimately methodically goes through a ROS. It's a waste of time and opens you up to liability (if positives documented and then no relevant work up). Work up the actual complaint. Everything else is negative. This is the ER, we don't have time for all this random ****. If you're here for vaginal bleeding, we are not working up your "chest pain."

If the patient is legitimately having an MI, they need to complain of chest pain or dyspnea or something and not check in to the ER for vaginal bleeding.

 

[WilcoWorld]

Also remember that if you document critical care time you don't need ROS for level 5 OR if there's a reason why you can't do ROS (altered, critically ill, intoxicated) you can just document that & skip the ROS.

 

[BoardingDoc]

As @southerndoc posted, the ability to select all other systems negative has not been allowed by several insurers. At a few places that I have worked including my current shop they have not allowed this option as it is frequently declined payment from insurance and charts down-coded. I'm hopeful the future will bring changes in charting requirements as this has certainly been a grey area with many EPs feeling like they have to be fraudulent. It is very difficult to be efficient and deliver appropriate care to level 5 patients asking a complete 10 system ROS.

That's crazy. I've just emailed our coders to see if that's something they've seen around here as well. If so, I'm happy to play the stupid game and come up with a fast and meaningless but technically valid way to ask about 10 ROS.

 

[pkwraith]

I don't know a single practicing staff ER physician who still legitimately methodically goes through a ROS. It's a waste of time and opens you up to liability (if positives documented and then no relevant work up). Work up the actual complaint. Everything else is negative. This is the ER, we don't have time for all this random ****. If you're here for vaginal bleeding, we are not working up your "chest pain."

If the patient is legitimately having an MI, they need to complain of chest pain or dyspnea or something and not check in to the ER for vaginal bleeding.

Except now, with "note transparency", they can troll through their notes and cue all the patient complaints of "they never wrote down my dizziness, chills, fatigue, numbness, weakness, ear pain, toe pain, armpit smell, chronic flatulence"

 

[Angry Birds]

I would simply say, if audited, "the patient did not complain of any of these other complaints, and therefore, I marked them as negative." Sue me.

 

[Vandalia]

I would simply say, if audited, "the patient did not complain of any of these other complaints, and therefore, I marked them as negative." Sue me.

Selective hearing loss is one of the most important skills for an EM physician, and yet is rarely taught in residency programs or tested on the ABEM oral exam.

 

[RustedFox]

Selective hearing loss is one of the most important skills for an EM physician, and yet is rarely taught in residency programs or tested on the ABEM oral exam.

Seriously.
The skill of "nonsense discarding" needs to be developed, early.

 

[Angry Birds]

Selective hearing loss is one of the most important skills for an EM physician, and yet is rarely taught in residency programs or tested on the ABEM oral exam.

I was fortunate to have attendings in residency who taught it to me. I am grateful to them.

 

[RoyBasch]

Except now, with "note transparency", they can troll through their notes and cue all the patient complaints of "they never wrote down my dizziness, chills, fatigue, numbness, weakness, ear pain, toe pain, armpit smell, chronic flatulence"

Time to turn it around:

"If it wasn't documented, then it didn't happen."

 

[gamerEMdoc]

Just asking “do you have pain anywhere” gets you a ton of systems. How have you been feeling lately nets psych/constitutional. Any problems breathing? Are you a diabetic and if so how have your sugars been running. Any rashes? Are you on any blood thinners.

Believe it or not, with those questions, I just reviewed all 14 systems.

 

[BoardingDoc]

As @southerndoc posted, the ability to select all other systems negative has not been allowed by several insurers. At a few places that I have worked including my current shop they have not allowed this option as it is frequently declined payment from insurance and charts down-coded. I'm hopeful the future will bring changes in charting requirements as this has certainly been a grey area with many EPs feeling like they have to be fraudulent. It is very difficult to be efficient and deliver appropriate care to level 5 patients asking a complete 10 system ROS.

Replying to this one again as I just heard back from our coders. Evidently (in our neck of the woods anyway) they haven't seen/heard of any instances of this and have said to go ahead and keep using the "all other systems negative" checkbox whenever we feel it appropriate. Maybe it's just a regional insurance company thing.

 

[Angry Birds]

Just asking “do you have pain anywhere” gets you a ton of systems. How have you been feeling lately nets psych/constitutional. Any problems breathing? Are you a diabetic and if so how have your sugars been running. Any rashes? Are you on any blood thinners.

Believe it or not, with those questions, I just reviewed all 14 systems.

"Do you have pain anywhere?"
"How have you been feeling lately?"
I would never ask any of that. That can open up so many cans of worms.
I do the opposite of what they taught us in medical school: I ask questions that are as close-ended as possible. "Does it hurt here? Can you point with one finger where your chest pain is? Do you also feel short of breath? Does it hurt to breathe?"
And I actually do physical exam before history. That has been a gamechanger for me.

 

[southerndoc]

Replying to this one again as I just heard back from our coders. Evidently (in our neck of the woods anyway) they haven't seen/heard of any instances of this and have said to go ahead and keep using the "all other systems negative" checkbox whenever we feel it appropriate. Maybe it's just a regional insurance company thing.

Perhaps so. Where one goes, others will follow. I can tell you exactly which insurers are doing this in private.

 

[RoyBasch]

Just asking “do you have pain anywhere” gets you a ton of systems. How have you been feeling lately nets psych/constitutional. Any problems breathing? Are you a diabetic and if so how have your sugars been running. Any rashes? Are you on any blood thinners.

Believe it or not, with those questions, I just reviewed all 14 systems.

The problem is: What if the patient answers in the affirmative to all of those, which they very easily could as they are fairly open ended. Yes I am having problems breathing, I do hurt "all over" and I think I have diabetes, not sure what my sugars are. The patient's actual chief complaint is dysuria by the way.

So you do what every experienced ER physician does a this point: "Review of Systems negative as marked except per HPI." Because what are you going to do? Start doing EKGs for the chest pain, CXR for the breathing problem, LFTs and Lipase for the abdominal pain, CMP for blood sugar, X rays and US for their leg pain? The patient is here for dysuria, this is--and needs to be--a quick in and out patient. If it's not, nursing will kill you, your group will kill you, patients rotting in the waiting room will kill you.

All this is coming from somebody who is very conservative in their practice and over-works patients in general. The complicated patients are complicated enough, you gotta let the easy ones be easy.

My point is if the ultimate point is to mark the ROS negative except the CC, why ask the questions at all, your essentially "doing a test" that "does not change management," which is something we as ER physicians try to avoid.

 

[Dr Mantis Toboggan]

The problem is: What if the patient answers in the affirmative to all of those, which they very easily could as they are fairly open ended. Yes I am having problems breathing, I do hurt "all over" and I think I have diabetes, not sure what my sugars are. The patient's actual chief complaint is dysuria by the way.

So you do what every experienced ER physician does a this point: "Review of Systems negative as marked except per HPI." Because what are you going to do? Start doing EKGs for the chest pain, CXR for the breathing problem, LFTs and Lipase for the abdominal pain, CMP for blood sugar, X rays and US for their leg pain? The patient is here for dysuria, this is--and needs to be--a quick in and out patient. If it's not, nursing will kill you, your group will kill you, patients rotting in the waiting room will kill you.

All this is coming from somebody who is very conservative in their practice and over-works patients in general. The complicated patients are complicated enough, you gotta let the easy ones be easy.

My point is if the ultimate point is to mark the ROS negative except the CC, why ask the questions at all, your essentially "doing a test" that "does not change management," which is something we as ER physicians try to avoid.

i often will leave the ROS blank for the obvious urgent care players.

 

[RoyBasch]

i often will leave the ROS blank for the obvious urgent care players.

Nice efficiency power move!

 

[RustedFox]

Nice efficiency power move!

Macros for the win.

 

[BoardingDoc]

The problem is: What if the patient answers in the affirmative to all of those, which they very easily could as they are fairly open ended. Yes I am having problems breathing, I do hurt "all over" and I think I have diabetes, not sure what my sugars are. The patient's actual chief complaint is dysuria by the way.

So you do what every experienced ER physician does a this point: "Review of Systems negative as marked except per HPI." Because what are you going to do? Start doing EKGs for the chest pain, CXR for the breathing problem, LFTs and Lipase for the abdominal pain, CMP for blood sugar, X rays and US for their leg pain? The patient is here for dysuria, this is--and needs to be--a quick in and out patient. If it's not, nursing will kill you, your group will kill you, patients rotting in the waiting room will kill you.

All this is coming from somebody who is very conservative in their practice and over-works patients in general. The complicated patients are complicated enough, you gotta let the easy ones be easy.

My point is if the ultimate point is to mark the ROS negative except the CC, why ask the questions at all, your essentially "doing a test" that "does not change management," which is something we as ER physicians try to avoid.

You only have to deal with that scenario with patients who present with actual high risk complaints. The dysuria patient doesn't need 10+ ROS questions answered as that chart is never going to be a lvl 5 visit anyway, and the lvl 4 visit and below requires only 2 ROS. Fever? Sx I care about? Done.

 

[Fox800]

"Review of systems is pan-positive."

 

[gamerEMdoc]

The problem is: What if the patient answers in the affirmative to all of those, which they very easily could as they are fairly open ended. Yes I am having problems breathing, I do hurt "all over" and I think I have diabetes, not sure what my sugars are. The patient's actual chief complaint is dysuria by the way.

So you do what every experienced ER physician does a this point: "Review of Systems negative as marked except per HPI." Because what are you going to do? Start doing EKGs for the chest pain, CXR for the breathing problem, LFTs and Lipase for the abdominal pain, CMP for blood sugar, X rays and US for their leg pain? The patient is here for dysuria, this is--and needs to be--a quick in and out patient. If it's not, nursing will kill you, your group will kill you, patients rotting in the waiting room will kill you.

All this is coming from somebody who is very conservative in their practice and over-works patients in general. The complicated patients are complicated enough, you gotta let the easy ones be easy.

My point is if the ultimate point is to mark the ROS negative except the CC, why ask the questions at all, your essentially "doing a test" that "does not change management," which is something we as ER physicians try to avoid.

I only ask a broad ROS in patients who are likely to meet a level 5 chart. If someone is coming in for dysuria, I'm not doing a big ROS. Understanding how charts are coded, and what is likely to be coded at a higher level, those are the ones I'll ask more questions on and check the "all systems reviewed" box.