Review of Systems Template with Examples

Review of Systems Template

This Review of Systems (ROS) template is crafted to assist clinicians in conducting a comprehensive symptom assessment by guiding them through targeted questions across all major organ systems. When integrated with s10.ai, this ROS template leverages AI technology to optimize clinical documentation by:

• Reducing manual note-taking by automatically generating structured ROS notes from patient interactions, covering systems such as cardiovascular, respiratory, neurological, and more.
• Adapting the level of review based on the clinical context, whether conducting a detailed screening for a new patient with multiple conditions or a focused evaluation during follow-up visits.
• Seamlessly integrating with Electronic Health Records (EHRs) to ensure compliance with evaluation and management (E/M) coding standards.

What is a Review of Systems Template?
A Review of Systems (ROS) template is a structured set of questions organized by organ systems to help clinicians identify current or past symptoms and uncover potential medical conditions. In the United States and Canada, it’s commonly called a "Review of Systems template," while in regions like the United Kingdom, Australia, and New Zealand, it’s known as a "systems enquiry" or "systems review" template. Despite regional naming differences, the goal remains consistent.

This article explores the benefits of using an ROS template, the types and levels of ROS documentation, the essential components of an ROS template, and current industry perspectives on ROS. Additionally, you can access customizable ROS templates tailored to your practice.

Review of Systems vs. Physical Exam: Key Differences
The ROS and physical exam are distinct components of patient evaluation, often confused by clinicians, residents, or students. Here’s a concise breakdown:

• ROS: Captures patient-reported symptoms during the history-taking phase to identify potential red flags, whether related to the chief complaint or not.
  Example: A patient reports fatigue but, through ROS, also mentions night sweats and weight loss, prompting further investigation.
• Physical Exam: Involves clinician-observed findings using techniques like inspection, palpation, percussion, or auscultation.
  Example: If chest pain is noted in the ROS, the clinician may perform heart and lung auscultation to identify murmurs or abnormal breath sounds.

Industry Perspectives on the Review of Systems
Recent changes in medical documentation guidelines have reshaped how clinicians approach the ROS. Since January 2021, the American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) revised E/M coding guidelines, eliminating the need for a comprehensive ROS and requiring only a "medically appropriate history and/or examination."

This shift has sparked debate: some clinicians view the ROS as an outdated requirement, while others emphasize its value in thorough patient assessments. Research shows that 11.36% of new diagnoses are identified solely through ROS, underscoring its role in detecting conditions that might otherwise go unnoticed.

The ROS remains a vital tool for accurate diagnoses and holistic care, even in a more flexible documentation landscape. It supports clinicians in delivering patient-centered, high-quality care. s10.ai, an AI-powered medical scribe with ambient listening technology, enhances this process by streamlining documentation and reducing administrative burden.

For example, Dr. Shelagh Fraser, Director of Medical Excellence and Innovation , a leading primary care provider in Indiana, stated:
“Before s10.ai, I spent 2–2.5 hours on notes after a full day of patient visits. Now, with s10.ai, that’s down to about 40 minutes. More importantly, it’s alleviated the mental strain of constant note-taking.”

Why Use a Review of Systems Template?

Adopting an ROS template is a standard practice across medical specialties, offering structure, precision, and efficiency. Here are the key benefits:

1. Promotes Consistency and Thoroughness: A template ensures no critical system is overlooked, standardizing the process and guaranteeing the right questions are asked consistently.
2. Reduces Cognitive Load: By providing a guided framework, the template minimizes decision fatigue and accelerates charting, especially during busy schedules.
3. Ensures Billing and Compliance: A well-designed ROS template aligns with E/M coding requirements, supporting accurate billing and reducing audit risks.
4. Uncovers Hidden Issues: The template prompts patients to report symptoms they might not otherwise mention, enabling earlier detection of related or underlying conditions.
5. Customizable for Specialty Needs: Whether in family medicine, cardiology, or psychiatry, the template can be tailored to focus on systems relevant to your patient population.

Sample Review of Systems Template

Review of Systems Template with Examples by s10.ai

All systems reviewed. Patient denies the following unless otherwise noted:

General: No fever, chills, weight loss, fatigue, malaise, night sweats, or weakness.
Skin: No rashes, itching, dryness, lesions, changes in skin color, hair loss, or nail changes.
Head: No headaches, dizziness, lightheadedness, or head trauma.
Eyes: No vision changes, eye pain, redness, discharge, photophobia, floaters, or double vision.
Ears: No hearing loss, tinnitus, ear pain, discharge, or vertigo.
Nose/Sinuses: No congestion, rhinorrhea, epistaxis, sinus pressure, sneezing, postnasal drip, or anosmia.
Mouth/Throat: No sore throat, hoarseness, ulcers, gum bleeding, dental pain, dry mouth, or dysphagia.
Neck: No pain, stiffness, swelling, lumps, or limited range of motion.
Breasts: No pain, lumps, nipple discharge, or skin changes.
Respiratory: No cough, dyspnea, wheezing, sputum, hemoptysis, or chest tightness.
Cardiovascular: No chest pain, palpitations, orthopnea, PND, edema, or claudication.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation, abdominal pain, bloating, heartburn, melena, or hematochezia.
Genitourinary: No dysuria, frequency, urgency, hematuria, incontinence, or flank pain.

Male: No penile discharge or erectile dysfunction.

Female: No vaginal discharge, pelvic pain, or abnormal bleeding. LMP normal.

Musculoskeletal: No joint pain, swelling, stiffness, back pain, or muscle weakness.
Neurological: No headaches, numbness, tingling, weakness, seizures, memory loss, or balance issues.
Psychiatric: No depression, anxiety, mood changes, sleep disturbances, or suicidal/homicidal ideation.
Endocrine: No heat/cold intolerance, polydipsia, polyuria, weight changes, or skin/hair changes.
Hematologic/Lymphatic: No easy bruising, prolonged bleeding, anemia, lymphadenopathy, or transfusion history.
Allergic/Immunologic: No seasonal or food allergies, frequent infections, autoimmune symptoms, or adverse drug reactions.

Three Types of Review of Systems with Examples

The CMS E/M coding guidelines outline three levels of ROS documentation, determining how many organ systems are reviewed during a patient encounter. These levels also guide what to include in an ROS template:

1. Problem Pertinent ROS: Focuses solely on the organ system tied to the chief complaint.
   Example:
   CC: Sore throat.
   ROS: Reports sore throat for 4 days. Denies cough or fever.
   Note: Only the ENT system is reviewed.
2. Extended ROS: Covers the system related to the chief complaint plus 2–9 additional systems, avoiding irrelevant systems to prevent overdocumentation.
   Example:
   CC: Follow-up for diabetes.
   ROS: Denies increased thirst or frequent urination. Reports occasional numbness in feet. No chest pain or shortness of breath.
   Note: Endocrine, neurological, and cardiovascular systems are reviewed, qualifying as an extended ROS.
3. Complete ROS: Includes at least 10 organ systems, typically used for comprehensive exams, with individual documentation for systems with findings and a general statement for others.
   Example:
   CC: Annual wellness visit.
   ROS:
   • Constitutional: No fever, chills, or weight changes.
   • Eyes: No blurred vision or eye pain.
   • ENT: Reports occasional nasal congestion, denies hearing loss.
   • Cardiovascular: No chest pain or palpitations.
   • Respiratory: Denies cough or wheezing.
   • Gastrointestinal: No nausea, vomiting, or diarrhea.
   • Genitourinary: No urinary changes.
   • Musculoskeletal: Reports mild back pain after prolonged sitting.
   • Neurological: No headaches or dizziness.
   • Psychiatric: Denies anxiety or mood changes.
     Note: Over 10 systems are reviewed, qualifying as a complete ROS.

Using an ROS template enhances clinical documentation, and s10.ai takes it further by enabling customizable, AI-driven templates that align with your practice’s unique needs, making documentation faster and more precise.

Streamline Your ROS Workflow with s10.ai
Here’s how s10.ai enhances your ROS process in three steps:

1. Transcribe: s10.ai listens to patient conversations in real-time, capturing symptom-related details across multiple systems, ensuring no critical information is missed, whether assessing chest pain in a cardiac patient or mood changes in a mental health consultation.
2. Transform: The AI organizes captured data into your preferred ROS format, mapping symptoms to the appropriate organ systems automatically.
3. Customize: Adjust your ROS template to suit your specialty or patient population with ease, whether you need a concise 10-point ROS for urgent care or a comprehensive 14-system review for annual exams.

Try S10.AI

Customizable Review of Systems Templates

14-Point Review of Systems Template

This comprehensive template covers all 14 CMS-recognized body systems, ideal for in-depth evaluations. Paired with s10.ai’s AI scribe, it ensures accurate, compliant documentation with minimal effort.

Template:

• Constitutional: Fever, weight loss/gain, fatigue, chills
• Eyes: Vision changes, pain, redness, double vision
• ENT (Ears, Nose, Throat): Hearing loss, sore throat, nasal congestion, ear pain
• Cardiovascular: Chest pain, palpitations, edema, irregular heartbeat
• Respiratory: Cough, shortness of breath, wheezing, chest tightness
• Gastrointestinal: Nausea, vomiting, abdominal pain, diarrhea, constipation
• Genitourinary: Urgency, frequency, dysuria, hematuria
• Musculoskeletal: Joint pain, stiffness, swelling, muscle weakness
• Integumentary: Rashes, lesions, itching, skin changes
• Neurological: Headaches, dizziness, numbness, seizures
• Psychiatric: Anxiety, depression, mood changes, sleep disturbances
• Endocrine: Heat/cold intolerance, excessive thirst, weight changes
• Hematologic/Lymphatic: Bruising, bleeding, swollen glands
• Allergic/Immunologic: Allergies, frequent infections, hives

10-Point Review of Systems Template

Tailored for focused visits, this template addresses 10 key systems, perfect for routine or urgent care settings. s10.ai streamlines documentation while maintaining compliance.

Template:

• Constitutional: Fever, weight changes, fatigue, night sweats
• Eyes: Blurred vision, eye pain, redness
• ENT (Ears, Nose, Throat): Ear pain, sore throat, sinus issues, hearing changes
• Cardiovascular: Chest pain, irregular heartbeat, swelling
• Respiratory: Cough, wheezing, shortness of breath
• Gastrointestinal: Nausea, diarrhea, constipation, abdominal discomfort
• Musculoskeletal: Muscle pain, joint stiffness, swelling
• Neurological: Headaches, seizures, tingling, dizziness
• Psychiatric: Mood changes, anxiety, depression
• Integumentary: Rashes, skin changes, lesions

Psychiatric Review of Systems Template

Designed for mental health professionals, this template focuses on domains like mood, sleep, cognition, and behavior, aligning with DSM-V criteria. s10.ai ensures clear, structured documentation.

Template: 

• Mood: Depression, anxiety, irritability, mood swings
• Sleep: Insomnia, hypersomnia, nightmares, sleep disturbances
• Cognition: Memory issues, concentration difficulties, confusion
• Psychosis: Hallucinations, delusions, disorganized thoughts
• Appetite: Increased/decreased appetite, significant weight changes
• Behavior: Agitation, impulsivity, withdrawal, compulsive behaviors
• Suicidal/Homicidal Ideation: Thoughts of self-harm or harm to others
• Substance Use: Alcohol, drugs, tobacco, caffeine use
• Energy: Fatigue, hyperactivity, lethargy
• Anxiety Symptoms: Panic attacks, excessive worry, restlessness

FAQs about Review of Systems Templates

How long does a comprehensive ROS take?
Typically 5–10 minutes, depending on patient complexity and clinician experience. Additional time may be needed for patients with multiple symptoms.

What is a basic ROS template?
A checklist of symptom-related questions organized by 14 body systems (e.g., respiratory, gastrointestinal, neurological) to screen for issues beyond the chief complaint or history of present illness.

Can an ROS template be customized for different specialties?
Yes, templates can be tailored to emphasize relevant systems. For example, a neurologist might prioritize neurological and musculoskeletal systems, while a psychiatrist focuses on psychiatric and cognitive symptoms.

What is a Review of Systems (ROS)?

A Review of Systems is a structured inventory of body systems obtained by asking a series of questions to identify any signs or symptoms a patient may be experiencing. It serves as a comprehensive screening tool to uncover health issues that might not have been mentioned in the chief complaint.

What is the purpose of a Review of Systems?

The primary purpose of an ROS is to gather a comprehensive picture of a patient's health. It helps clinicians identify potential medical concerns across various body systems, which aids in making an accurate diagnosis and developing an effective treatment plan. A thorough ROS can uncover diagnoses that might otherwise be missed.

What are the 14 systems in a standard Review of Systems?

The 14 systems recognized for ROS purposes are:

*   Constitutional Symptoms (e.g., fever, weight loss)

*   Eyes

*   Ears, Nose, Mouth, Throat

*   Cardiovascular

*   Respiratory

*   Gastrointestinal

*   Genitourinary

*   Musculoskeletal

*   Integumentary (skin and/or breast)

*   Neurological

*   Psychiatric

*   Endocrine

*   Hematologic/Lymphatic

*   Allergic/Immunologic

What is the difference between a Review of Systems and a Physical Exam?

A Review of Systems is based on patient-reported symptoms and history, while a physical exam is based on a clinician's objective findings. For example, a patient might report chest pain during the ROS, and the clinician would then use the physical exam to listen to the heart and lungs for any abnormalities.

What are the different types of Review of Systems?

There are three main types of ROS:

*   Problem Pertinent ROS: Inquires only about the system directly related to the problem identified in the History of Present Illness (HPI).

*   Extended ROS: Inquires about the system directly related to the problem(s) in the HPI and a limited number of additional systems (two to nine).

*   Complete ROS: Inquires about the system(s) directly related to the problem(s) in the HPI plus all additional organ systems (a minimum of ten).

How do you document a Review of Systems?

To document a ROS, a healthcare provider systematically goes through a checklist of body systems, asking the patient about any symptoms for each. The provider then records any positive or pertinent negative findings for each system reviewed. This is often done using a standardized template.

Can a Review of Systems template be customized for different medical specialties?

Yes, ROS templates can and should be customized for different specialties. For instance, a cardiologist's template would likely have a more detailed cardiovascular and respiratory section, whereas a psychiatrist would focus more on psychiatric and neurological symptoms.

What is a "problem pertinent" ROS?

A problem-pertinent ROS focuses on the organ system directly related to the patient's chief complaint. For example, if a patient's chief complaint is an earache, the ROS would focus on the ears, nose, mouth, and throat system.

What is an "extended" ROS?

An extended ROS reviews the system related to the chief complaint plus two to nine additional systems. For instance, a patient with hypertension might have their cardiovascular, neurological, and respiratory systems reviewed.

What is a "complete" ROS?

A complete ROS is the most thorough type, reviewing at least 10 organ systems. This is typically performed during comprehensive exams, such as a new patient visit, to get a full picture of the patient's health.