The Review of Systems (ROS) is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing. The Centers for Medicare and Medicaid Services (CMS) recognizes 14 systems:
- Constitutional symptoms (i.e. fever, weight loss, vital signs)
- Ears, nose, mouth, throat
There are a couple of document guidelines for the ROS that you should be aware of when it comes to your patient’s medical record. A ROS obtained during an earlier encounter does not have to be documented again if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by describing any new ROS or noting there has been no change in the information. The physician will also have to document the date and location of the earlier ROS in the present encounter. Another guideline is that a staff member may document the ROS in the medical record as long as there is evidence that the provider reviewed their documentation.
You have to reference the date of the last ROS if referring to this in your present note. You cannot state review of systems unchanged from last visit, the date is needed.
Looking at the History Table, you will note that there are three levels to choose from:
- A “problem pertinent” ROS inquires about the system directly related to the problems(s) identified in the HPI. Documentation needs to include the positive responses and pertinent negatives for the system related problem.
- An “extended” ROS inquires about the system directly related to the problems(s) identified in the HPI and a limited number of additional systems. Documentation needs to include the positive responses and pertinent negatives for two to nine systems.
- A “complete” ROS inquires about the system directly related to the problems(s) identified in the HPI plus all additional body systems. At least ten systems need to be reviewed. Those systems with positive responses and pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is allowed.
Note the wording above for each of the three levels ROS needs to be directly related to the problem.