Wiki Review of Systems ROS) Template

[Catherine@i1Consulting.com]

Hello,

I'm working with a practice that requested sample templates or documentation of how the clinicians do an ROS on each patient. Historically, they were just stating that a 10 point Review of Systems was performed but it was not documented what those 10 systems were...

I know that the physicians need to define which 10 body systems/organs they will review and document in the patient's record, and I understand that the 10 systems/organs identified by the physicians should be written up as a guideline or procedure that can be provided to an auditor if requested, but can anyone provide me with a screen shot of an EHR template or pdf of what your providers are using to document their ROS?

Thank you in advance for your help!

 

[mhstrauss]

The audit tool that I use lists these:

1. Constitutional (weight loss, etc.)
2. Eyes
3. Ears, nose, mouth, throat
4. Card/vasc
5. Resp
6. GI
7. GU
8. Musculo
9. Integ
10. Neuro
11. Psych
12. Endo
13. Hem/lymph
14. Allerg/Immun


This is from the '97 Documentation Guidelines