Review of Systems

An initial case history typically includes a long list of symptoms related to every system in the body. Our clinical experience has demonstrated that doctors often have distinctly varied lists of items in their respective “Review of Systems” (ROS). These can be long lists containing 50-100+ items. Then, doctors normally ask follow-up questions about the issues that have been checked by the patient.

I know from conversations with colleagues that items I give great weight to during ROS are not on their radar – and the reverse is true as well.

The preface on the first Encounter is a good place to write a synopsis of the ROS. It might read: Review of systems from case history form revealed: positive for asthma (trigger:
pollen) controlled by medication; high blood pressure (Dr. Barnes, internist
monitoring) and enlarged prostate (Dr. Barnes, internist monitoring).

Alternatively, the ECLIPSE KIOSK software can be used for new patient entry and has an extensive ROS built-in. It’s automatically imported to the patient’s EHR as a document when the new patient is imported into ECLIPSE.

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Category
Encounter / SOAP
Written by
Karen Walters, D.C.
Posted
August 9, 2011

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