Review of systems
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a
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]
Examples
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
|
masses
|
Eyes | 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
|
loss of consciousness, claudication
|
Respiratory
|
haemoptysis, shortness of breath, exercise intolerance
|
Gastrointestinal
|
melaena), dry heaves of the bowels (tenesmus )
|
Genitourinary
|
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
|
eczema , excessive dryness and/or discoloration. Breast pain, soreness, lumps, or discharge.
|
Neurological
|
psychiatric symptoms
|
Psychiatric
|
financial binges
|
Endocrine
|
Adrenal : difficult to treat hypertension, chronic low blood pressure, orthostatic symptoms, darkening of skin in non-sun exposed placesReproductive (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 |
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 |
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]
Relationship to history
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.
"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.
"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" than it can be counted in the ROS as well as the HPI.
In the above
[4]
References
- PMID 17390256.
- ^ "www.cms.gov" (PDF). Archived from the original (PDF) on 2011-03-22. Retrieved 2011-02-27.
- ISBN 978-0-7817-8058-2. Retrieved 27 February 2011.
- ^ a b "Evaluation and Management Services Guide" (PDF). www.cms.gov. December 2010. Archived from the original (PDF) on 2012-04-11. Retrieved 2011-02-27.