ALiEM - November 2nd, 2016 - By: Watsjold B, Dyer S, and Burkhardt J
"The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.”
This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?.."
