Review of systems documentation: Difference between revisions

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REVIEW OF SYSTEMS:
==Background==
CONST: [] Negative for fever, body aches and chills.
*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>
HENT: []Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.
*Despite this change, a focused ROS remains clinically valuable for capturing relevant symptoms and supporting the clinical narrative
EYES:[] Negative for discharge/pain or vision changes.  
*CMS recognizes 14 organ systems for ROS documentation
RESP:[] Negative for cough/hemoptysis and shortness of breath.
*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
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]
==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
 
==Sample ROS (Complete)==
'''REVIEW OF SYSTEMS:'''
 
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.
 
CV: Negative chest pain, difficulty breathing, palpitations.
 
ABD: Negative pain, nausea, vomiting.
 
GU: Negative increased frequency, dysuria, blood in urine or stool.
 
MUSC: Negative for muscle aches, edema.
 
SKIN: Negative rash, lesions/sores.
 
NEURO: Negative headache, dizziness, weakness.
 
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 pages}}
 
==References==
<references/>
 
[[Category:Documentation]]

Latest revision as of 19:04, 25 March 2026

Background

  • 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[1]
  • 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

CMS-Recognized Organ Systems

  1. Constitutional
  2. Eyes
  3. Ears, Nose, Mouth and Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
  10. Neurologic
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

Sample ROS (Complete)

REVIEW OF SYSTEMS:

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.

CV: Negative chest pain, difficulty breathing, palpitations.

ABD: Negative pain, nausea, vomiting.

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

MUSC: Negative for muscle aches, edema.

SKIN: Negative rash, lesions/sores.

NEURO: Negative headache, dizziness, weakness.

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 Pages

References

  1. ↑ American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient and Other Services Code and Guideline Changes. 2023.
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