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