Medical review of system template

The patient is receiving radiation therapy currently. ROS Examples 1. The patient has mild fatigue. No blurry vision or loss of vision. ENT: No loss of hearing, sinus drainage, difficulty swallowing. No heart attack or palpitations.

No diarrhea or constipation. SKIN: No rashes or itching. No mood swings or other mental disorder. No thyroid disorders. No thrombocytopenia or bleeding disorders. No recent fever, chills, or severe weight changes. He states he has gained some weight recently. No jaundice, rash, itching, lumps, or cellulitis. The only problem was the gangrene in his right leg.

Eyes: No visual changes or diplopia. Nose: No stuffiness, drainage, itching, or hay fever. No epistaxis. Throat and Mouth: No hoarseness, dysphagia, bleeding from his gums, leukoplakia, or sore throat.

NECK: No goiter, masses, nodules, or adenopathy. No edema. He states he does cough up some sputum at times. She is a postmenopausal woman who has had no postmenopausal bleeding. Denies muscle weakness. Limitation in range of motion. Positive for diabetes. ROS Examples 3. No recent changes. Denies recent fever.

She did report that she has had recent vision difficulty and knows that she needs to see an ophthalmologist. Denies eye pain, inflammation, discharge, lesions. Reports no difficulty with hearing. No earaches or recent infections. Denies mouth pain. Denies bleeding of the gums. Denies sores and lesions in the mouth. Denies trouble swallowing or hoarseness. No neck pain.

Denies limitation of motion. Denies lumps or swollen glands. Reports no changes in her breasts. Reports no nipple discharge, rash or swelling. No chest pain with breathing. Denies wheezing. Denies shortness of breath. Denies chest pain, cyanosis, fatigue, or trouble breathing on exertion. No history of heart murmur, hypertension, CAD, or anemia. Denies numbness or tingling. Denies swelling of the legs. The patient reports having a good appetite with no recent changes. Denies heartburn or indigestion or pain or nausea or vomiting.

Denies difficulty with urination, urgency or frequency. Denies flank pain. REVIEW OF SYSTEMS: No fevers, chills, sweats, headaches, visual disturbances, ear, nose or throat complaints, cough, shortness of breath, sputum production, retrosternal chest pain, radiating pain, jaw pain, tooth pain, arm pain, hypertension, diabetes, dyslipidemia, heart or valve problems, heart attacks, strokes, seizures, thyroid illness, cancer.

He had no periumbilical pain, abdominal pain, nausea, vomiting or diarrhea, constipation, hematochezia, melena, dark tarry stools, rashes, skin breakdown, numbness, tingling or paralysis. He denies any history of chronic kidney disease, peptic ulcer disease, gastritis, heartburn or reflux. Normal Review of Systems Transcription Samples.

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You cannot state review of systems unchanged from last visit, the date is needed. Note the wording above for each of the three levels ROS needs to be directly related to the problem.

Documentation needs to include the positive responses and pertinent negatives for the system related problem.

Documentation needs to include the positive responses and pertinent negatives for two to nine systems.