Review of systems documentation - Revision history

Rossdonaldson1 at 19:04, 25 March 2026

2026-03-25T19:04:18Z

← Older revision		Revision as of 19:04, 25 March 2026
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	==Background==		==Background==
	*The ROS is a systematic inventory of symptoms reported by the patient		*Under the 2023 CMS E/M guidelines, the ROS is no longer a required element for determining ED billing level — billing is now driven by MDM or total time<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>
	*Under the 2023 CMS E/M guidelines, the ROS is ~~'''~~no longer a required element~~'''~~ for determining ED billing level — billing is now driven by ~~'''~~MDM or total time~~'''~~<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>
	*Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative		*Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative
	*CMS recognizes ~~'''~~14 organ systems~~'''~~ for ROS documentation		*CMS recognizes 14 organ systems for ROS documentation
	*A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required		*A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required

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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Physical exam documentation]]
	*[[Billing]]

	{{Documentation pages}}		{{Documentation pages}}

Danbot: Expanded: added Background with 2023 CMS update, CMS organ systems list, Documentation Tips, psych system to sample, references, See Also, documentation pages template

2026-03-24T11:03:01Z

Expanded: added Background with 2023 CMS update, CMS organ systems list, Documentation Tips, psych system to sample, references, See Also, documentation pages template

← Older revision		Revision as of 11:03, 24 March 2026
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	~~REVIEW OF SYSTEMS:~~		==Background==
			*The ROS is a systematic inventory of symptoms reported by the patient
			*Under the 2023 CMS E/M guidelines, the ROS is '''no longer a required element''' for determining ED billing level — billing is now driven by '''MDM or total time'''<ref>American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.</ref>
			*Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative
			*CMS recognizes '''14 organ systems''' for ROS documentation
			*A "complete" ROS (≥10 systems) was historically required for Level 5 billing; this is no longer the case under current guidelines but may still be institutionally required

	~~CONST: Negative for fever~~, ~~body aches~~ and ~~chills.~~		==CMS-Recognized Organ Systems==
			#Constitutional
			#Eyes
			#Ears, Nose, Mouth and Throat
			#Cardiovascular
			#Respiratory
			#Gastrointestinal
			#Genitourinary
			#Musculoskeletal
			#Integumentary (skin and/or breast)
			#Neurologic
			#Psychiatric
			#Endocrine
			#Hematologic/Lymphatic
			#Allergic/Immunologic

	~~HENT~~: ~~Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.~~		==Sample ROS (Complete)==
			'''REVIEW OF SYSTEMS:'''

	EYES: Negative for discharge/pain or vision changes.		CONST: Negative for fever, body aches and chills.

			HEENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.

			EYES: Negative for discharge/pain or vision changes.

	RESP: Negative for cough/hemoptysis and shortness of breath.		RESP: Negative for cough/hemoptysis and shortness of breath.

	CV: Negative chest pain, difficulty breathing, palpitations.		CV: Negative chest pain, difficulty breathing, palpitations.

	ABD: Negative pain, nausea, vomiting.		ABD: Negative pain, nausea, vomiting.

	GU: Negative ~~increase~~ frequency, dysuria, blood in urine or stool.		GU: Negative increased frequency, dysuria, blood in urine or stool.

	MUSC: Negative for muscle aches, edema.		MUSC: Negative for muscle aches, edema.

	SKIN: Negative rash, lesions/sores.		SKIN: Negative rash, lesions/sores.
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	NEURO: Negative headache, dizziness, weakness.		NEURO: Negative headache, dizziness, weakness.

	~~[brackets added~~ to be ~~uploaded into dragon for quick editing. This~~ ROS ~~meets CMS standards~~ for ~~level 5~~ documentation]		PSYCH: Negative for depression, anxiety, suicidal ideation.

			==Documentation Tips==
			*Document '''pertinent positives and negatives''' relevant to the chief complaint
			*"All other systems reviewed and negative" is acceptable shorthand for non-pertinent systems after documenting specific positive/negative findings
			*The ROS should be '''obtained from the patient''' (or caregiver), not the physician's exam findings
			*Documenting the ROS in the HPI is acceptable as long as it is clearly identifiable

			==See Also==
			*[[Documentation for emergency physicians]]
			*[[Physical exam documentation]]
			*[[Billing]]

			{{Documentation pages}}

			==References==
			<references/>

	[[Category:Documentation]]		[[Category:Documentation]]

TannerLeeFrey at 22:18, 1 December 2021

2021-12-01T22:18:59Z

← Older revision		Revision as of 22:18, 1 December 2021
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	REVIEW OF SYSTEMS:		REVIEW OF SYSTEMS:

	CONST: [] Negative for fever, body aches and chills.		CONST: Negative for fever, body aches and chills.

	HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.		HENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.

	EYES:[] Negative for discharge/pain or vision changes.		EYES: Negative for discharge/pain or vision changes.

	RESP:[] Negative for cough/hemoptysis and shortness of breath.		RESP: Negative for cough/hemoptysis and shortness of breath.

	CV: []Negative chest pain, difficulty breathing, palpitations.		CV: Negative chest pain, difficulty breathing, palpitations.

	ABD:[] Negative pain, nausea, vomiting.		ABD: Negative pain, nausea, vomiting.

	GU: []Negative increase frequency, dysuria, blood in urine or stool.		GU: Negative increase frequency, dysuria, blood in urine or stool.

	MUSC: []Negative for muscle aches, edema.		MUSC: Negative for muscle aches, edema.

	SKIN: []Negative rash, lesions/sores.		SKIN: Negative rash, lesions/sores.

	NEURO:[] Negative headache, dizziness, weakness.		NEURO: Negative headache, dizziness, weakness.

	[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]		[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]

	[[Category:Documentation]]		[[Category:Documentation]]

Rossdonaldson1 at 10:58, 25 November 2021

2021-11-25T10:58:22Z

← Older revision		Revision as of 10:58, 25 November 2021
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	[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]		[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]

			[[Category:Documentation]]

TannerLeeFrey at 01:22, 19 November 2021

2021-11-19T01:22:08Z

← Older revision		Revision as of 01:22, 19 November 2021
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	REVIEW OF SYSTEMS:		REVIEW OF SYSTEMS:

	CONST: [] Negative for fever, body aches and chills.		CONST: [] Negative for fever, body aches and chills.

TannerLeeFrey at 01:21, 19 November 2021

2021-11-19T01:21:40Z

← Older revision		Revision as of 01:21, 19 November 2021
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	REVIEW OF SYSTEMS:		REVIEW OF SYSTEMS:
	CONST: [] Negative for fever, body aches and chills.		CONST: [] Negative for fever, body aches and chills.

	HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.		HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.

	EYES:[] Negative for discharge/pain or vision changes.		EYES:[] Negative for discharge/pain or vision changes.

	RESP:[] Negative for cough/hemoptysis and shortness of breath.		RESP:[] Negative for cough/hemoptysis and shortness of breath.

	CV: []Negative chest pain, difficulty breathing, palpitations.		CV: []Negative chest pain, difficulty breathing, palpitations.

	ABD:[] Negative pain, nausea, vomiting.		ABD:[] Negative pain, nausea, vomiting.

	GU: []Negative increase frequency, dysuria, blood in urine or stool.		GU: []Negative increase frequency, dysuria, blood in urine or stool.

	MUSC: []Negative for muscle aches, edema.		MUSC: []Negative for muscle aches, edema.

	SKIN: []Negative rash, lesions/sores.		SKIN: []Negative rash, lesions/sores.

	NEURO:[] Negative headache, dizziness, weakness.		NEURO:[] Negative headache, dizziness, weakness.

	[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]		[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]

TannerLeeFrey: Created page with "REVIEW OF SYSTEMS: CONST: [] Negative for fever, body aches and chills. HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling. EYES:[] Negati..."

2021-11-19T01:20:12Z

Created page with "REVIEW OF SYSTEMS: CONST: [] Negative for fever, body aches and chills. HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling. EYES:[] Negati..."

New page

REVIEW OF SYSTEMS:
CONST: [] Negative for fever, body aches and chills.
HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.
EYES:[] Negative for discharge/pain or vision changes.
RESP:[] Negative for cough/hemoptysis and shortness of breath.
CV: []Negative chest pain, difficulty breathing, palpitations.
ABD:[] Negative pain, nausea, vomiting.
GU: []Negative increase frequency, dysuria, blood in urine or stool.
MUSC: []Negative for muscle aches, edema.
SKIN: []Negative rash, lesions/sores.
NEURO:[] Negative headache, dizziness, weakness.

[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]