The Review of Systems (ROS) is a structured, systematic inventory of symptoms related to all major body systems, conducted after the practitioner has gathered the patient’s History of Present Illness (HPI). It functions as a comprehensive checklist, moving beyond the immediate chief complaint to screen for current or past health issues the patient may have overlooked or not thought relevant. The primary purpose of this inquiry is to uncover any subtle or seemingly unrelated signs and symptoms that could alter the diagnostic picture, ensuring a complete clinical assessment. A well-documented ROS is an inventory of what the patient reports, providing a broad overview of their physiological state.
The Standard System Categories
The structure of the Review of Systems categorizes symptoms by major organ system, providing a standardized framework for clinical documentation. Regulatory bodies recognize a set of 14 distinct categories that serve as mandatory checkpoints for a comprehensive review.
These categories cover all major physiological areas:
- Constitutional (e.g., fever, weight change, fatigue)
- Eyes (e.g., vision changes)
- Ears, Nose, Mouth, and Throat (ENT) (e.g., hearing loss, sore throat)
- Cardiovascular (e.g., chest pain, palpitations)
- Respiratory (e.g., cough, shortness of breath)
- Gastrointestinal (e.g., nausea, abdominal pain)
- Genitourinary (e.g., painful urination, frequency)
- Musculoskeletal (e.g., joint pain, stiffness)
- Neurological (e.g., headaches, dizziness, numbness)
- Integumentary (Skin and Breast) (e.g., rashes, itching, lesions)
- Psychiatric (e.g., mood changes)
- Endocrine (e.g., hormonal balance issues)
- Hematologic/Lymphatic (e.g., bleeding or bruising tendencies)
- Allergic/Immunologic (e.g., allergic responses, recurrent infections)
These 14 categories establish the structural skeleton of the ROS document and must be addressed, even if the patient reports no symptoms in a given area. The number of systems reviewed determines the level of the ROS, ranging from a problem-pertinent review (one system) to a complete review (ten or more systems). Clinicians use these categories to ensure a standardized inquiry.
Documentation Methodology: Structuring Findings
Writing a Review of Systems requires precise language, clearly distinguishing between what the patient reports and what they deny. The preferred format uses the system categories as headings, followed by a brief summary of the findings. This structured presentation, often using bulleted lists or short paragraphs, enhances readability and allows subsequent reviewers to quickly identify areas of concern.
For positive findings, the documentation should briefly describe the symptom the patient endorses, such as “Cardiovascular: reports occasional palpitations.” Unlike the HPI, the ROS does not require a detailed, chronological account of the symptom’s onset, duration, or modifying factors. If a symptom warrants such detail, it must be fully expanded upon in the HPI section, with only a brief positive mention remaining in the ROS.
A comprehensive ROS consists of negative findings, documented as pertinent negatives. These are symptoms the patient denies having that are relevant to the presenting problem or the systems under review. Clear phrases such as “denies chest pain, orthopnea, or edema” are used to document these absences of symptoms for the Cardiovascular system. The use of the word “denies” confirms that the practitioner specifically asked about the symptom, and the patient responded negatively.
When a complete review of ten or more systems is performed, a documentation shortcut is permitted after individually listing all positive responses and pertinent negatives. A single, summarizing statement, such as “All other systems negative,” accounts for the remaining systems that were reviewed but yielded no symptoms. This concise approach satisfies the requirement for a complete review without becoming overly lengthy.
Ensuring Accuracy and Completeness in Documentation
Maintaining accuracy in the Review of Systems relies on drawing a clear line between the symptom inventory and the detailed narrative of the History of Present Illness (HPI). The HPI is a deep dive into the chief complaint, utilizing elements like location, quality, severity, and context to tell the story of the current illness. In contrast, the ROS is a rapid, system-by-system screening tool, and symptoms documented here should remain brief.
A common documentation pitfall is confusing the level of detail, where a symptom already detailed in the HPI is simply restated in the ROS. Any finding that requires a comprehensive description to be medically understood belongs exclusively in the HPI. For instance, if the chief complaint is chest pain, the HPI will describe its radiation and timing, while the ROS will simply state the system is positive for chest pain and list pertinent negatives.
To ensure the integrity of the medical record, the written ROS must clearly indicate that the information was obtained directly from the patient or from a reliable source such as a family member. Explicitly stating “ROS obtained from patient” confirms the source of the subjective data. This attribution is important because the ROS is based solely on patient reporting and does not incorporate objective findings from the physical examination or laboratory tests.
Completeness in the ROS is demonstrated by documenting every system that was reviewed during the patient encounter. Failing to document a system implies that the inquiry was not performed, leading to an incomplete clinical record. Accounting for each system—whether through a positive report, a pertinent negative, or a summary statement for a full review—ensures the written document accurately reflects the patient assessment.