Review of systems documentation: Difference between revisions

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REVIEW OF SYSTEMS:
REVIEW OF SYSTEMS:
CONST: [] Negative for fever, body aches and chills.  
 
HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.  
CONST: Negative for fever, body aches and chills.  
EYES:[] Negative for discharge/pain or vision changes.  
 
RESP:[] Negative for cough/hemoptysis and shortness of breath.
HENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.  
CV: []Negative chest pain, difficulty breathing,  palpitations.  
 
ABD:[] Negative pain, nausea, vomiting.
EYES: Negative for discharge/pain or vision changes.  
GU: []Negative increase frequency, dysuria, blood in urine or stool.   
 
MUSC: []Negative for muscle aches, edema.  
RESP: Negative for cough/hemoptysis and shortness of breath.
SKIN: []Negative rash, lesions/sores.
 
NEURO:[] Negative headache, dizziness, weakness.
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]
[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]
[[Category:Documentation]]

Latest revision as of 22:18, 1 December 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]

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