From the Guidelines
When documenting that a patient cannot provide a review of systems (ROS), you should clearly state the reason for the inability to obtain this information, as supported by the American College of Physicians' policy position paper 1. The correct way to document this is to state "Unable to obtain ROS due to [specific reason]" in the ROS section of your note, where the reason might include patient intubation, altered mental status, critical condition, language barrier with no interpreter available, or severe pain limiting communication.
- This documentation is essential for billing and compliance purposes, as it demonstrates your effort to perform a complete assessment despite limitations, in line with the principle that clinical documentation should support patient care and improve clinical outcomes through enhanced communication 1.
- If partial ROS information can be gathered from family members or other sources, you should document that information along with its source, and then note which elements could not be obtained and why.
- The use of macros and templates, as mentioned in the study 1, may be valuable in improving the completeness and efficiency of documentation, particularly for standardized terminology such as the review of systems and physical examination findings.
- Effective and ongoing EHR documentation training of clinical personnel, as emphasized in the study 1, is crucial for ensuring that documentation is accurate, complete, and efficient.
From the Research
Documenting a Patient's Inability to Provide a Review of Systems (ROS)
- The medical record should include comprehensive and detailed documentation of a patient's inability to provide a ROS, as this is critical to patient care and may be relevant in allegations of negligence 2.
- When a patient is unable to provide a ROS, it may be due to cognitive impairment, which can be evaluated and managed using a systematic approach, including interviewing a knowledgeable informant and performing a thorough mental status examination 3.
- Cognitive impairment can be caused by various factors, including mild cognitive impairment (MCI), dementia, and peripheral artery disease (PAD) 4, 5, 6.
- In cases where a patient is unable to provide a ROS due to cognitive impairment, the medical record should reflect the patient's condition and any efforts made to obtain the necessary information from alternative sources, such as family members or caregivers.
- The documentation should include the reason for the patient's inability to provide a ROS, any alternative methods used to obtain the necessary information, and any relevant medical history or diagnoses that may be contributing to the patient's condition 2.