Wednesday, September 5, 2012

ROS Vs. Physical Exam




What is the difference between ROS and Physical Exam?

When reading a chart note, it can be difficult to distinguish between elements belonging to the review of systems (ROS), and those elements that are relevant to the exam.

The ROS are written or verbal “questions and answers” relevant to signs or symptoms the patient is experiencing at the time of service. Often, the ROS is gathered by having the patient complete a history or intake form given to the patient at the front desk check-in. The form includes a list of questions, on which the patient “checks off” and briefly explains his or her signs and symptoms.

The ROS may also occur verbally with the provider or other staff. For instance, an assistant may ask the patient, “Do you have any problems breathing? Do you have shortness of breath when exercising, walking, climbing the stairs?” If ancillary staff documents the ROS, the provider must review the information to use it for E/M selection.

The provider might document the patient’s response in a note as briefly as, ”Patient states his chest hurts when he coughs, but not when he takes a deep breath. No SOB. No complaints of pain in joints. No problems sleeping.”

If the provider uses a subjective, objective, assessment, and plan (SOAP) documentation format, the ROS elements should appear under the heading “Subjective.”

In contrast to the elements of the ROS, the elements of an exam are actual visual or “hands-on” findings. For example, the provider uses an otoscope to inspect the middle ear visually, an ophthalmoscope to check the eyes and their reaction to light, and a stethoscope to listen to lung, heart, and bowel sounds.

The bottom line: When reading the notes, decide if the notation is something the patient answered, or if it is something the provider observed. A question that is answered belongs to the ROS, whereas something the provider sees, hears, or measures upon examination is an element of the exam.

31 comments:

  1. This helped a lot! (i'm a student)
    THanks!!!

    ReplyDelete
  2. This helped a lot! (i'm a student)
    THanks!!!

    ReplyDelete
  3. nice post...thanks for sharing valuable information..

    medical coding training in ameerpet

    ReplyDelete
  4. Positive site, where did u come up with the information on this posting? I'm pleased I discovered it though, ill be checking back soon to find out what additional posts you include. CBD Gummies

    ReplyDelete
  5. Thank you again for all the knowledge you distribute,Good post. I was very interested in the article, it's quite inspiring I should admit. I like visiting you site since I always come across interesting articles like this one.Great Job, I greatly appreciate that.Do Keep sharing! Regards, mask production machine 10

    ReplyDelete
  6. How beautifully all the feelings have been conveyed through writing.
    medical face mask making machine

    ReplyDelete
  7. Pretty good post. I have just stumbled upon your blog and enjoyed reading your blog posts very much. I am looking for new posts to get more precious info. Big thanks for the useful info. disposble face mask manufacturer china

    ReplyDelete
  8. We have sell some products of different custom boxes.it is very useful and very low price please visits this site thanks and please share this post with your friends. disposable mask manufacturer china

    ReplyDelete
  9. This is also a very good post which I really enjoyed reading. It is not every day that I have the possibility to see something like this.. medical masks

    ReplyDelete
  10. I definitely enjoying every little bit of it. It is a great website and nice share. I want to thank you. Good job! You guys do a great blog, and have some great contents. Keep up the good work.
    surgical mask manufacturer china3,medical mask manufacturers china

    ReplyDelete
  11. I definitely enjoying every little bit of it. It is a great website and nice share. I want to thank you. Good job! You guys do a great blog, and have some great contents. Keep up the good work.
    surgical mask manufacturer china3,medical mask manufacturers china

    ReplyDelete
  12. I definitely enjoying every little bit of it. It is a great website and nice share. I want to thank you. Good job! You guys do a great blog, and have some great contents. Keep up the good work.
    surgical mask manufacturer china3,medical mask manufacturers china

    ReplyDelete
  13. I think that thanks for the valuabe information and insights you have so provided here. berberine diabetes type 1

    ReplyDelete
  14. Hey There. I found your blog using msn. This is a very well written article. I’ll be sure to bookmark it and come back to read more of your useful info. Thanks for the post. I’ll definitely return. vapor chamber

    ReplyDelete
  15. The post is written in very a good manner and it contains many useful information for me thnku soo mchh..

    washable mask

    ReplyDelete
  16. This comment has been removed by the author.

    ReplyDelete
  17. This is a great inspiring article.I am pretty much pleased with your good work.You put really very helpful information. Keep it up. Keep blogging. Looking to reading your next post. CBD Edibles

    ReplyDelete
  18. You made such an interesting piece to read, giving every subject enlightenment for us to gain knowledge. Thanks for sharing the such information with us to read this... cfa level 1 mock exam pdf

    ReplyDelete
  19. Awesome article, it was exceptionally helpful! I simply began in this and I'm becoming more acquainted with it better! Cheers, keep doing awesome! cfa level 1 pdf

    ReplyDelete
  20. I think this is an informative post and it is very useful and knowledgeable. therefore, I would like to thank you for the efforts you have made in writing this article. cfa level 1 material

    ReplyDelete
  21. When you use a genuine service, you will be able to provide instructions, share materials and choose the formatting style. Lean Manufacturing

    ReplyDelete
  22. Nice blog and absolutely outstanding. You can do something much better but i still say this perfect.Keep trying for the best. PMP Dumps

    ReplyDelete
  23. (Except if the children are engaged with sports at their school). No concerns however, in view of Youth Coach Brian Grasso and his International Youth Conditioning Association, there is currently a developing pattern of youth explicit exercise programming in fitness offices all through the world. fitnessbond.com

    ReplyDelete
  24. we are professional face mask machine manufacturer in China ,we offer automatic surgicalface mask machines ,KN95 mask machine ,N95 Mask making machine ,KF94 mask machine with good quality and after sales service ,if you have any needs or questions about mask machine ,please feel free to let us know ,www.deqimachine.com ,sales@deqimachine.com ,whatsapp : +86 15966681218

    ReplyDelete
  25. The website is looking bit flashy and it catches the visitors eyes. Design is pretty simple and a good user friendly interface. equipamentos de musculação brasília

    ReplyDelete
  26. Dr. Johnson defines English essay writing as "a loose sally of the mind, and irregular, indigested piece, not a regular and orderly performance". It has also been called, "the after-dinner monologue of an interesting and well-informed man". It has been called by Saintsbury as, "a work of prose art". These definitions do not apply to such philosophical essay as Locke's Essay Concerning Human Understanding or to Pope's Essay on Criticism and Essay on Man. Hugh Walker has divided essay into two types-Essays per excellence and compositions to which custom has assigned the name. the true essay is essentially personal. English essay writing belongs to the literature of self-expression. Question Paper 2021

    ReplyDelete
  27. Online education is getting popular day by day but it doesn't mean that we can think that the traditional education system is dying. There are still more benefits of the traditional education system than the online. 12th Model Paper 2021

    ReplyDelete
  28. Online education is getting popular day by day but it doesn't mean that we can think that the traditional education system is dying. There are still more benefits of the traditional education system than the online. 12th Model Paper 2021

    ReplyDelete