A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests. [1]
Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. Different sources describe slightly different systems of organizing the organ systems. However, the following are examples of what can be included. Unspecified and other symptoms can't consider for both HPI and ROS:
There are 14 systems recognized by the Centers for Medicare and Medicaid Services: [2]
System | Examples |
---|---|
Constitutional symptoms | weight loss, day sweats, fatigue/malaise/lethargy, sleeping pattern, appetite, fever, itch/rash, recent trauma, lumps/bumps/masses |
Eyes | visual changes, headache, eye pain, double vision, scotomas (blind spots), floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs amaurosis fugax) |
Ears, nose, mouth, and throat (ENT) | Runny nose, frequent nose bleeds (epistaxis), sinus pain, stuffy ears, ear pain, ringing in ears (tinnitus), gingival bleeding, toothache, sore throat, pain with swallowing (odynophagia) |
Cardiovascular | chest pain, shortness of breath, exercise intolerance, PND, orthopnoea, oedema, palpitations, faintness, loss of consciousness, claudication |
Respiratory | cough, sputum, wheeze, haemoptysis, shortness of breath, exercise intolerance |
Gastrointestinal | abdominal pain, unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion, bloating, cramping, loss of appetite, food avoidance, nausea/vomiting, diarrhea/constipation, inability to pass gas (obstipation), vomiting blood (haematemesis), bright red blood per rectum (BRBPR, hematochezia), foul smelling dark black tarry stools (melaena), dry heaves of the bowels (tenesmus) |
Genitourinary | Urinary: Irritative vs Obstructive symptoms: Micturition – incontinence, dysuria, haematuria, nocturia, polyuria, hesitancy, terminal dribbling, decreased force of stream Genital: Vaginal – discharge, pain, Menses – frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus, menarche, menopause, contraception (if relevant), date of last smear test and result |
Musculoskeletal | pain, misalignment, stiffness (morning vs day long; improves/worsens with activity), joint swelling, decreased range of motion, crepitus, functional deficit, arthritis |
Integumentary/Breast | pruritus, rashes, stria, lesions, wounds, incisions, acanthosis nigricans, nodules, tumors, eczema, excessive dryness and/or discoloration. Breast pain, soreness, lumps, or discharge. |
Neurological | Special senses – any changes in sight, smell, hearing and taste, seizures, faints, fits, funny turns, headache, pins and needles (paraesthesiae) or numbness, limb weakness, poor balance, speech problems, sphincter disturbance, cognitive and psychiatric symptoms |
Psychiatric | depression, sleep patterns, anxiety, difficulty concentrating, body image, work and school performance, paranoia, anhedonia, lack of energy, episodes of mania, episodic change in personality, expansive personality, sexual or financial binges |
Endocrine | Hyperthyroid: prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite, tremor, palpitations, visual disturbances; Hypothyroid – prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation, dry skin Diabetes: polydipsia, polyuria, polyphagia (constant hunger without weight gain is more typical for a type I diabetic than type II), symptoms of hypoglycemia such as dizziness, sweating, headache, hunger, tongue dysarticulation Adrenal: difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed places Reproductive (female): menarche, cycle duration and frequency, vaginal bleeding irregularities, use of birth control pills, changes in sexual arousal or libido Reproductive (male): difficulty with erection or sexual arousal, depression, lack of stamina/energy |
Hematologic/lymphatic | anemia, purpura, petechia, results from routine hemolytic diseases screening, prolonged or excessive bleeding after dental extraction / injury, use of anticoagulant and antiplatelet drugs (including aspirin), family history of hemophilia, history of a blood transfusion, refused for blood donation |
Allergic/immunologic | "Difficulty breathing" or "choking" (anaphylaxis) as a result of exposure to anything (and state what; e.g. "bee sting"). Swelling or pain at groin(s), axilla(e) or neck (swollen lymph nodes/glands), allergic response (rash/itch) to materials, foods, animals (e.g. cats); reaction to bee sting, unusual sneezing (in response to what), runny nose or itchy/teary eyes; food, medication or environmental allergy test(s) results. |
The questions may be asked of the patient in a "head to toe" manner. [3]
Type of history | CC | HPI | ROS | Past, family, and/or social |
---|---|---|---|---|
Problem focused | Required | Brief | N/A | N/A |
Expanded problem focused | Required | Brief | Problem pertinent | N/A |
Detailed | Required | Extended | Extended | Pertinent |
Comprehensive | Required | Extended | Complete | Complete |
For CMS, a "problem pertinent" ROS is limited to the problem(s) identified in the HPI; an "extended" ROS covers an additional 2 to 9 systems, and a "complete" ROS covers at least 10 additional systems. The chances of double dipping should be avoided while taking ROS from History. There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. [4]
This established patient has had a fever with sore/scratchy throat and severe headache for the past three days. He has had a little nausea but no vomiting. He said his pain is relieved with cold drinks and ibuprofen.
In the above example if you take throat as location in HPI, you can not take sore/scratchy throat in ROS as ENT element. Most of the double dipping will happen in ENT section since it is a combined system. Of note, some would say that the statement of "No known allergies" could be calculated as part of the review of systems (ROS). The statement suggests the patient is not allergic to any medications, which is commonly part of the "past medical history" element. [4]
The patient was brought up by an aunt; Patient having nasal problems for last 4 days, symptoms including runny nose / rhinorrhea. Denies cough, no fever, pneumonia, severe headache for the past three days.
In the above example, if you take Nose as location, you can not take runny nose/rhinorrhea in ROS as an ENT element. Double dipping is against the rules. The common double dipping example (above) uses the elements of HPI (location and associated signs and symptoms) for both the HPI and the ROS. Double dipping may increase revenue by making it possible to qualify for a higher level of history and as such be considered fraud or abuse. There is a fine line between the signs and symptoms that patient shares in the HPI and those obtained via the ROS. The ROS is a distinct review of systems. For example: if the documentation reads "'patient states that her hip has been painful' credit is not given in both the HPI 'location' and to the MSK (musculoskeletal) review of systems." It goes on to explain that if the patient's complaint is followed by "no other MSK issues", then it can be counted in the ROS as well as the HPI. [4]
Streptococcal pharyngitis, also known as streptococcal sore throat, is pharyngitis caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.
The common cold or the cold is a viral infectious disease of the upper respiratory tract that primarily affects the respiratory mucosa of the nose, throat, sinuses, and larynx. Signs and symptoms may appear in as little as two days after exposure to the virus. These may include coughing, sore throat, runny nose, sneezing, headache, and fever. People usually recover in seven to ten days, but some symptoms may last up to three weeks. Occasionally, those with other health problems may develop pneumonia.
Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.
Sore throat, also known as throat pain, is pain or irritation of the throat. The majority of sore throats are caused by a virus, for which antibiotics are not helpful.
Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under 2 weeks.
Rhinitis, also known as coryza, is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip.
An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx or trachea. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold. Most infections are viral in nature, and in other instances, the cause is bacterial. URTIs can also be fungal or helminthic in origin, but these are less common.
Ipratropium bromide, sold under the brand name Atrovent among others, is a type of anticholinergic medication which is applied by different routes: inhaler, nebulizer, or nasal spray, for different reasons.
Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. Complications include peritonsillar abscess (quinsy).
A peritonsillar abscess (PTA), also known as a quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Complications may include blockage of the airway or aspiration pneumonitis.
Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.
Rhinorrhea, also spelled rhinorrhoea or rhinorrhœa, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies or certain viral infections, such as the common cold or COVID-19. It can be a side effect of crying, exposure to cold temperatures, cocaine abuse, or drug withdrawal, such as from methadone or other opioids. Treatment for rhinorrhea may be aimed at reducing symptoms or treating underlying causes. Rhinorrhea usually resolves without intervention, but may require treatment by a doctor if symptoms last more than 10 days or if symptoms are the result of foreign bodies in the nose.
Katrina cough is a putative respiratory illness thought to be linked to exposure to mold and dust after the 2005 Hurricane Katrina in the United States. First described by doctors treating patients in the metro New Orleans area symptoms include cough, sinus headache, congestion, runny nose, and sore throat, and pink eye. This condition may make immunocompromised individuals more susceptible to bacterial bronchitis and sinusitis. Most patients are treated with antihistamines, nasal sprays, and/or antibiotics.
Adenovirus infection is a contagious viral disease, caused by adenoviruses, commonly resulting in a respiratory tract infection. Typical symptoms range from those of a common cold, such as nasal congestion, coryza and cough, to difficulty breathing as in pneumonia. Other general symptoms include fever, fatigue, muscle aches, headache, abdominal pain and swollen neck glands. Onset is usually two to fourteen days after exposure to the virus. A mild eye infection may occur on its own, combined with a sore throat and fever, or as a more severe adenoviral keratoconjunctivitis with a painful red eye, intolerance to light and discharge. Very young children may just have an earache. Adenovirus infection can present as a gastroenteritis with vomiting, diarrhoea and abdominal pain, with or without respiratory symptoms. However, some people have no symptoms.
The schedule for childhood immunizations in the United States is published by the Centers for Disease Control and Prevention (CDC). The vaccination schedule is broken down by age: birth to six years of age, seven to eighteen, and adults nineteen and older. Childhood immunizations are key in preventing diseases with epidemic potential.
Mometasone, also known as mometasone furoate, is a steroid medication used to treat certain skin conditions, hay fever, and asthma. Specifically it is used to prevent rather than treat asthma attacks. It can be applied to the skin, inhaled, or used in the nose. Mometasone furoate, not mometasone, is used in medical products.
A cold sore is a type of herpes infection caused by the herpes simplex virus that affects primarily the lip. Symptoms typically include a burning pain followed by small blisters or sores. The first attack may also be accompanied by fever, sore throat, and enlarged lymph nodes. The rash usually heals within ten days, but the virus remains dormant in the trigeminal ganglion. The virus may periodically reactivate to create another outbreak of sores in the mouth or lip.
Throat irritation can refer to a dry cough, a scratchy feeling at the back of the throat, a sensation of a lumpy feeling, something stuck at the back of the throat, or possibly a feeling of dust in the throat. The symptoms are unpleasant and usually temporary, but occasionally signifies a more serious health issue, such as laryngitis.
Nonallergic rhinitis is rhinitis—inflammation of the inner part of the nose—not caused by an allergy. Nonallergic rhinitis displays symptoms including chronic sneezing or having a congested, drippy nose, without an identified allergic reaction with allergy testing being normal. Other common terms for nonallergic rhinitis are vasomotor rhinitis and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis rather than allergic rhinitis. Other symptoms that are more specific to non-allergic rhinitis include ear plugging or discomfort with eustachian tube dysfunction, headaches, sinus pressure, and muffled hearing. Common triggers for non-allergic rhinitis include irritants such as tobacco smoke, cleaning agents, or abrupt changes in ambient temperature.
The symptoms of COVID-19 are variable depending on the type of variant contracted, ranging from mild symptoms to a potentially fatal illness. Common symptoms include coughing, fever, loss of smell (anosmia) and taste (ageusia), with less common ones including headaches, nasal congestion and runny nose, muscle pain, sore throat, diarrhea, eye irritation, and toes swelling or turning purple, and in moderate to severe cases, breathing difficulties. People with the COVID-19 infection may have different symptoms, and their symptoms may change over time.