How to Distinguish ROS from Exam
When reading a chart note, it can be difficult to distinguish between elements belonging to the review of systems (ROS), and those elements that are relevant to the exam.
The ROS are written or verbal “questions and answers” relevant to signs or symptoms the patient is experiencing at the time of service. Often, the ROS is gathered by having the patient complete a history or intake form given to the patient at the front desk check-in. The form includes a list of questions, on which the patient “checks off” and briefly explains his or her signs and symptoms.
The ROS may also occur verbally with the provider or other staff. For instance, an assistant may ask the patient, “Do you have any problems breathing? Do you have shortness of breath when exercising, walking, climbing the stairs?” If ancillary staff documents the ROS, the provider must review the information to use it for E/M selection.
The provider might document the patient’s response in a note as briefly as, ”Patient states his chest hurts when he coughs, but not when he takes a deep breath. No SOB. No complaints of pain in joints. No problems sleeping.”
If the provider uses a subjective, objective, assessment, and plan (SOAP) documentation format, the ROS elements should appear under the heading “Subjective.”
In contrast to the elements of the ROS, the elements of an exam are actual visual or “hands-on” findings. For example, the provider uses an otoscope to inspect the middle ear visually, an ophthalmoscope to check the eyes and their reaction to light, and a stethoscope to listen to lung, heart, and bowel sounds.
The bottom line: When reading the notes, decide if the notation is something the patient answered, or if it is something the provider observed. A question that is answered belongs to the ROS, whereas something the provider sees, hears, or measures upon examination is an element of the exam.