Below are examples of what ROS documentation should reflect, taken from the 1995 documentation guidelines for E/M:
C. Review of Systems
ROS is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
There are three types of ROS:
1) Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system – the ear – is reviewed:
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CC: Earache.
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ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.
2) Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems – cardiovascular and respiratory – are reviewed:
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CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.�
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ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.
Evaluation & Management Services Guide 11
3) Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:
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CC: Patient complains of “fainting spell.�
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ROS:
o Constitutional: weight stable, + fatigue.
o Eyes: + loss of peripheral vision.
o Ear, Nose, Mouth, Throat: no complaints.
o Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.
o Respiratory: + shortness of breath on exertion.
o Gastrointestinal: appetite good, denies heartburn and indigestion.
+ episodes of nausea. Bowel movement daily; denies constipation or loose stools.
o Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
o Skin: + clammy, moist skin.
o Neurological: + fainting; denies numbness, tingling, and tremors.
o Psychiatric: denies memory loss or depression. Mood pleasant.
You should also reiterate to the physicians that little golden rule, if it's not documented, it didn't happen.