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GeneralReview of Systems
Comprehensive 14-point review of systems completed with patient
Meaning
A thorough inquiry into the patient's current and past health status across 14 organ systems.
Clinical Context
Used to document a complete review of systems encompassing all major organ systems, ensuring comprehensive patient evaluation.
Example Usage
"Comprehensive 14-point review of systems completed with patient; all systems negative except as noted above."
Usage Context
This phrase is used to summarize a complete and systematic inquiry into the patient's health status, typically following a detailed exploration of each system.
Related Phrases
Review of systemsROS completeAll systems negative
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Frequently Asked Questions
Common questions about using medical phrases in clinical documentation
When documenting "Comprehensive 14-point review of systems completed with patient" in your clinical notes, ensure it's placed in the appropriate section (Review of Systems) and provides clear, accurate information about the patient's condition. Always follow your institution's documentation guidelines and ensure the phrase accurately reflects the patient's clinical status.
This phrase is clinically significant because used to document a complete review of systems encompassing all major organ systems, ensuring comprehensive patient evaluation. It helps healthcare providers understand the patient's condition and make informed decisions about diagnosis and treatment planning.
While this phrase is commonly used in General, similar documentation may be applicable across multiple specialties when the clinical context is appropriate. Always ensure the phrase accurately describes the patient's condition regardless of the specialty context.