When dealing with clinical documentation of an evaluation and management service, what purpose does the phrase "Negative in detail" serve for the review of systems? Please explain your answer in detail. Are there any other phrases that could be used as well? What are they?
What will be an ideal response?
The answer should include any (or all) of the following:
? In the event the clinician reviews all fourteen-organ systems during the review of systems, and the patient denies any sign or symptom for a portion of the review of systems, one single phrase may reflect the asymptomatic nature of this review.
? This phrase abbreviates the amount of documentation required to reflect the in-depth nature of this review of systems interview.
? The other phrases that could also reflect an asymptomatic review of systems are:
? Remainder of review of systems is unremarkable,
? Remainder of ROS is negative in detail,
? Or another variation that closely equates in meaning.
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