What is the best description of review of systems?

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.”

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

CMS Definition & Requirements

The ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced”. CMS recognizes the following organ systems* for ROS (1995 E/M Documentation Guidelines, PDF):

1. Constitutional
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic

*Organ systems: A complete ROS must document systems, not regions of the body. This is an important distinction, e.g. Eyes and ENMT count separately, but Head and HEENT don’t count.

You can document 4 types of ROS, depending on how many of the possible 14 systems are reviewed:

Work Smarter, Not Harder: Resuscitating ROS

How do you make this section useful?

• Offload pertinent positives and negatives from the HPI into ROS.
• Organize your history with HPI first, then ROS, and PFSH last (mimicking how CMS arranges the E/M guidelines) so you can document a concise HPI statement and move directly to ROS. This will make your charting efficient, yet effective and billable.
• Use the ROS as a cognitive backstop. As a junior resident documenting ROS, I often realized I had forgotten certain history questions, did not have enough information to exclude an item on my differential, or that something the patient said did not fit with the rest of the picture, prompting me to re-evaluate my differential.
• Have a quick, rehearsed set of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of breath? Vomiting or diarrhea? Painful urination? Rashes? Joint pain or swelling? Numbness or tingling? Changes in mood? Heat or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question set to your practice setting and specific patients.

Final Tips

• One item– positive, negative, or normal– will suffice for each system.
• If you use dot phrases or macros, have a 2-4 system ROS for most patients and a complete ROS for patients that will reach E/M level 5. Consider also having a separate pediatric ROS.
• Always document at least 2 systems to prevent downcoding to an E/M level 2-3.
• ROS can be obtained by ancillary staff or by patient questionnaire, as long as the physician reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: “I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient.” Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
• A complete ROS can be a hybrid, listing pertinent positives and negatives by system, and then a notation indicating “All other systems are negative.”
• Both caveats used in the introduction are valid examples per CMS. If you give a number of systems in your caveat, you must list that number of systems afterwards, so the second version is more straightforward.

A series of questions concerning each organ system and region of the body, asked of the patient during history taking and physical examination in order to gain an optimal understanding of the patient's presenting illness and medical history.

A sample ROS follows: General: The examiner should determine any history of fatigue, travel to other climates or countries, recent weight change, chills, fever, and lifestyle change in the patient. How many persons occupy the patient's dwelling? What is the patient's relationship to the persons with whom he or she lives? Is it a happy home? What are the patient's hobbies and outside interests? How does the patient usually exercise? Does the patient have pets? Any history of military service? Any job-related illnesses? Any sexual partners? Any use of injected drugs? Any recent hospitalizations or illnesses?

Skin: Is the patient experiencing any rash, itching, sunburn, change in the size of moles, vesicles, or hair loss?

Head, face, and neck: Does the patient have headaches, migraine, vertigo, stiffness, pain, or swelling? Has there been trauma to this area?

Eyes: Does the patient wear glasses? When were the eyes last examined for visual acuity and glaucoma? Is the patient experiencing pain, diplopia, scotomata, itch, discharge, redness, or infection?

Ears: Does the patient have acute or chronic hearing loss, pain, discharge, tinnitus, or vertigo? Is there a history of failure to adjust to descent from a high altitude?

Nose: Does the patient have any dryness, crust formation, bleeding, pain, discharge, obstruction, malodor, or sneezing? How acute is the patient's sense of smell?

Mouth and teeth: The patient should be asked about any soreness, ulcers, pain, dryness, infection, hoarseness, bleeding gums, swallowing difficulty, bruxism, or temporomandibular syndrome. What is the condition of the patient's teeth (real or false)?

Breasts: Has the patient had any pain, swelling, tenderness, lumps, bleeding from the nipple, infection, or change in the ability of the nipples to become erect? Has plastic surgery been done, and if so, were implants used?

Respiratory: Has the patient had any cough, pain, wheezing, sputum production (including character of sputum), hemoptysis, or exposure to persons with contagious diseases such as tuberculosis? Is there a history of occupational or other exposure to asbestos, silica, chickens, parrots, or a dusty environment? The presence of dyspnea, cyanosis, tuberculosis, pneumonia, and pleurisy should be determined. If pulmonary function tests were done, the date or dates should be recorded. The extent and duration of all forms of tobacco use should be determined.

Cardiac: The examiner should determine the following: angina, dyspnea, orthopnea, palpitations, heart murmur, heart failure, myocardial infarction, surgical procedures on coronary arteries or heart valves, history of stress tests or angiography, hypertension, rheumatic fever, cardiac arrhythmias, exercise tolerance, history of athletic participation (including jogging and running) and if these are current activities, the dates of electrocardiograms if they were ever taken.

Vascular:` Has the patient experienced claudication, cold intolerance (esp. of the extremities), frostbite, phlebitis, or ulcers (esp. of the extremities) due to poor blood supply?

Gastrointestinal. The examiner should assess the patient's appetite, history of recent weight gain or loss, and whether the patient has been following a particular diet for gaining or losing weight. Is the patient a vegetarian? Has he or she had any difficulty in swallowing? Anorexia, nausea, vomiting (including the character of the vomitus), diarrhea and its possible explanation (such as foreign travel or food poisoning), belching, constipation, change in bowel habits, melena, hemorrhoids and history of surgery for this condition, use of laxatives or antacids, jaundice, hepatitis, and other liver disease should be determined.

Renal; urinary and genital tract: The examiner should take a history of kidney or bladder stones and date of last occurrence, dysuria, hematuria, pyuria, nocturia, incontinence, urgency, antibiotics used for urinary tract infections, bed-wetting, sexually transmitted diseases, libido, sexual partners, penile or urethral discharge, and frequency of sexual activity.

Women should be questioned regarding any vulval pruritus, vaginal discharge, vaginal malodor, history of menarche, frequency and duration of menstrual periods, amount of flow, type of menstrual protection used, type or types of contraception and douches used, and the total number of pregnancies, abortions, miscarriages, and normal deliveries. The number, sex, age, and health status of living children, and the cause of death of children who died, should be determined. Vaginal, cervical, and uterine infections; pelvic inflammatory disease; tubal ligation; dilation and curettement; hysterectomy; and dyspareunia should be recorded. Any history of the mother's use of diethylstilbestrol while pregnant with the patient should be determined.

Men should be asked about vasectomy, scrotal pain or swelling, and urinary hesitancy or double voiding.

Musculoskeletal: The examiner should ask about muscle twitches, pain, heat, tenderness, swelling, loss of range of motion or strength, cramps, sprains, strains, trauma, fractures, stiffness, back pain, osteoporosis, and character regarding time of day of onset and duration (esp. with respect to the effect of exercise, back pain, and osteoporosis).

Hematological: The examiner should record history of anemia, bleeding, bruising, hemarthrosis, hemophilia, sickle cell disease or trait, recent blood loss, transfusions received, and blood donation. Did the patient receive a transfusion at a time when blood was not being screened for hepatitis or AIDS? Was the patient ever turned down as a blood donor?

Endocrine: The patient should be questioned about sexual maturation and development, weight change, tolerance to heat or cold (esp. with respect to other persons in the same environment), dryness of hair and skin, hair loss, and voice change. Any change in the rate of beard growth in men, development of facial hair in women, increase in or loss of libido, polyuria, polydipsia, polyphagia, pruritus, diabetes, exophthalmos, goiter, unexplained flushing, and sweating should be noted.

Nervous system.: Has the patient experienced any recent change in ability to control muscular activity, or any syncope, stroke (shock), seizures, tremor, coordination, sensory disturbance, falls, pain, change in memory, dizziness, or head trauma?

Emotional and psychological status: Has there been a history of psychiatric illness, anxiety, depression, overactivity, mania, lassitude, change in sleep pattern, insomnia, hypersomnia, nightmares, sleepwalking, hallucinations, feeling of unreality, paranoia, phobias, obsessions, compulsions, criminal behavior, increase in or loss of libido, or suicidal thoughts? Is the patient satisfied with his or her occupation and with life in general? What is his or her marital and divorce record? Has there been family discord? Does the patient attend religious services? The patient's employment history and any recent job changes, educational history and achievement, and self-image should be assessed.