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. | |||
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. | |||
NEURO: | 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]