Daily Bolus of LR: Documentation of the History (ROS)

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May 10, 2011 by dailybolusoflr

Documentation of the History

The History is the cornerstone of your chart.

It is comprised of FOUR main factors:

1. The Chief Complaint (CC)

2. The History of Present Illness (HPI)

3. Review of Systems (ROS)

4. The Past, Family, and/or Social History (PFSH)

It is the first of the essential components for good documentation, as well as for the creation of a billable chart. Today we will discuss the third one.

3. Review of Systems (ROS)

a. There are a total of 14 possible systems

• Constitutional symptoms (fever, weight loss, etc)

• Eyes

• Ears, nose, mouth, throat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary (skin and/or breast)

• Neurological

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

o For Level 1 charts- you do not need ROS

o For Level 2 and 3 charts- you need a Pertinent ROS, which is 1 ROS

o For Level 4 charts- you need an Extended ROS, which is at least 2 ROS but no more than 9

o For Level 5 charts- you need a Complete ROS, which is 10 or more ROS

o It is not acceptable to simply say “ROS negative.” You can say 14 point ROS negative except as documented in the HPI; however, you MUST actually do the 14 point ROS!

Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions

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