Review of Systems

A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests. Read more at Wikipedia.



You are in the "Most Common" section of this website which deals with the most common occurrences of sentences and normal values in medical report. Read below to know more about the most common Review of Systems.


Constitutional
The patient is not a good historian, could not get a good history, most of them was taken from the chart. The patient is in good general health. The patient denies fevers, chills, nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath, wheezing, dysuria, suicidal ideation, homicidal ideation, auditory or visual hallucinations. No headaches. No vision changes. No appetite changes or weight loss. The patient denies any fever, shaking chills, productive or nonproductive cough.

Eyes
No headaches or visual disturbance. No retinal problems, cataracts, or glaucoma. The patient wears glasses. The patient had bilateral cataract surgeries in the past.

ENT
No hearing changes noted. The patient denies nosebleed, bad breath, or sore throat. The patient experiences frequent upper respiratory tract infections.

Cardiovascular
No chest pain or pressure. The patient does have documented PAF and second-degree AV block type I. The patient denies chest pain, shortness of breath, or palpitations.

Respiratory
Negative for cough and hemoptysis. No history of asthma or COPD. Negative for orthopnea and paroxysmal nocturnal dyspnea.

Gastrointestinal
Negative for nausea or vomiting. No abdominal pain, nausea, vomiting, or diarrhea. The patient denies any blood in the stool. The patient had gallstones removed in the past. The patient had EGD positive for Barrette's esophagus. The patient denies any blood per rectum. No change in bowel habits.

Genitourinary
Negative for dysuria, hematuria, or urinary incontinence. The patient had hysterectomy and bilateral salpingo-oophorectomy. The patient had tubal ligation. The patient has benign prostatic hypertrophy. No urinary tract problems. The patient has no dysuria, frequency, or hesitency. Frequent urinary tract infections noted.

Musculoskeletal
Positive for chronic global weakness. No swelling or painful joints.

Neurologic
No history of TIA, CVA, or seizure activity. The patient denies stroke or seizure disorder.

Psychiatric
No evidence of mania. No evidence of racing thoughts or grandiosity, or expansive or elevated mood is noted. No evidence of hallucinations, illusions, delusions, or anxiety symptoms reported. No panic symptoms are reported. No PTSD symptoms. No suicidal or homicidal ideations. No evidence of panic attacks, posttraumatic stress disorder or eating disorder. There is no evidence of grandiosity or racing thoughts. No evidence of eating disorder is noted. There is some decreased need for sleep and some psychomotor agitation and periods of increased talking. No evidence of frank PTSD or eating disorder is reported.

Integumentary
Negative for skin rashs. No evidence of jaundice. Negative for psoriasis or scleroderma.

Endocrine
Negative for hypothyroidism. Negative for Addison's disease. Negative for Cushing's syndrome.
Transcription tips
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Side Headings
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Client Specifications
Guidelines set by the client or the hospital to do their work in a certain specified format is called client specification.  AAMT guidelines are the fundamental rules which every Medical Transcriptionist should know.  AAMT guidelines gives you an overall information about specifications and/or rules of transcription...
Keyboard Shortcuts
Command over computer keyboard is important in the field of Medical Transcription. You may have a good typing speed, but of what use if you do not know the keyboard shortcuts. Moving in the document with ease is very essential. Look at the keyboard, see closely on keys "F" and "J"; you can see hyphen-like markings on those keys...
Home Transcription
If an MT works from home it is called home-based transcription. MTs working from home are called HMTs (Home Medication Transcriptionist) or IMTs (Independent Medical Transcriptionist). Who is fit to take up home based transcription work and what are its requirements...



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