Template for the ROS?

Unknown
edited May 2017 in Orthopedics
Good Afternoon,



Can a physician use a template when documenting the ROS? I have 1 provider
that always dictates "otherwise negative" and nothing else. I have explained
that this is an unacceptable statement and he would like to start using a
template. I review each note and guide him to what he needs to document but
he does not want to take the time to do this.



Any suggestions would be greatly appreciated.



Thank you in advance



Diane Maguire, CPC, CEMC

Somers Orthopaedic Surgery & Sports Medicine Group, PLLC

664 Stoneleigh Ave., Ste. 300

Carmel, NY 10512

Tel: (845) 230-5158

Fax: (845) 278-4321

Email: dmaguire@somersortho.com

www.somersortho.com

Comments

  • Unknown
    edited May 2017
    Thank you Kristin, yes I did let advise this physician and he rather just use a template for each patient that states "reviewed with the patient and documented in the chart" is this acceptable? He feels it takes too much time to dictate the systems with positive or pertinent negative responses.

    All the other physicians are documented their notes correctly. I have one stubborn physician:-(
  • Unknown
    edited May 2017
    Yes I agree and thank you for your responses Kristin. I have said this numerous of times to this provider. Even the other physicians have said the same thing to this provider.
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