What is an example of a complete ROS in documentation?

A complete Review of Systems (ROS) in medical documentation involves a comprehensive approach, addressing all relevant systems to provide a thorough overview of a patient's health status. The correct answer states, "Denies fevers and all other symptoms were negative," which indicates that the clinician systematically reviewed various body systems and confirmed that no other significant symptoms were present.

This thoroughness encapsulates the intent of a complete ROS, ensuring that the document reflects an exhaustive assessment rather than a partial view. The phrase "denies fevers" implies active questioning about that specific symptom, while "all other symptoms were negative" suggests that the clinician has assessed other systems and found no relevant complaints or issues. This level of detail is essential for ensuring comprehensive patient care and appropriate coding for services rendered.

In contrast, the other responses either lack detail or do not provide a comprehensive view of the patient's systems. For instance, stating "Symptoms unknown but history provided" does not convey any information about the review of systems. Similarly, "Only respiratory issues are noted" focuses narrowly on one system, and "Patient says they feel fine" does not reflect an evaluation of the broader systems available. Therefore, the option describing the negative responses across multiple systems exemplifies the completeness expected in a thorough ROS