Review of systems documentation: Difference between revisions
(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...") |
No edit summary |
||
| Line 1: | Line 1: | ||
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] | ||
Revision as of 01:21, 19 November 2021
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]