A review of systems (ROS) is a brief, structured sweep across body systems that helps you catch symptoms tied to the visit and spot hidden risks. It is not a scavenger hunt; it is a fast, patient-centered screen that backs up your history and steers the exam. The classic description calls it an inventory of body systems gathered through questions, and that framing still holds true today. See the American College of Cardiology’s overview of a Review of Systems for the common structure many teams use.
Doing A Review Of Systems Step By Step
Anchor the ROS to the chief concern and the timeline. Start with the system most likely linked to the reason for the visit, then fan out only as far as the story needs. Ask closed questions first, then open the door for short clarifications in the patient’s words. Keep each prompt plain, one symptom at a time, and avoid stacking multiple ideas in a single line.
Set The Purpose
State what you are doing in a sentence: “I’m going to run through a quick symptom checklist to make sure I’m not missing anything.” That one line builds trust and keeps the pace steady. Sit at eye level, pause between items, and watch for nonverbal cues that hint at a “yes” the patient hesitates to say out loud.
Keep It Focused
Use a short list of screens for each system. Stop when further screening will not change your decisions today. If the visit is focused, a targeted ROS beats a long recital. If the story is vague or the patient is frail, a broader pass makes sense. Either way, aim for clarity over length.
Core Screens And Red Flags By System
Use the prompts below as a fast start. Say the words your patient uses; avoid jargon when a simpler word works.
| System | Fast Screens | Red Flags |
|---|---|---|
| Constitutional | Fevers, chills, night sweats, weight change, fatigue? | Unintentional weight loss; persistent fever |
| Eyes | Changes in vision, double vision, pain, discharge? | Sudden vision loss; eye pain with vision change |
| Ears/Nose/Throat | Hearing change, ear pain, nasal congestion, sore throat, trouble swallowing? | Drooling or stridor; muffled voice with fever |
| Cardiovascular | Chest pain, palpitations, leg swelling, trouble lying flat? | Crushing chest pain; new syncope |
| Respiratory | Cough, shortness of breath, wheeze, sputum or blood? | Resting dyspnea; hemoptysis |
| Gastrointestinal | Nausea, vomiting, heartburn, pain, stool change, blood? | Black or bloody stools; persistent vomiting |
| Genitourinary | Burning, frequency, urgency, blood, flank pain? | Anuria; gross hematuria with clots |
| Musculoskeletal | Joint pain, stiffness, swelling, muscle aches? | Hot swollen joint; rapidly spreading redness |
| Skin | Rash, itching, color change, wounds? | Rapidly spreading rash; painful purpura |
| Neurologic | Headache, weakness, numbness, tingling, imbalance, seizures? | New focal weakness; worst headache of life |
| Psychiatric | Mood change, anxiety, sleep trouble, thoughts of self-harm? | Active suicidal thoughts; unsafe behavior |
| Endocrine | Heat or cold intolerance, thirst, urination change? | Confusion with polyuria and vomiting |
| Hematologic/Lymphatic | Easy bruising, bleeding, swollen glands? | Spontaneous bleeding; rapidly enlarging node |
| Allergic/Immunologic | Hay fever, asthma flares, frequent infections? | Anaphylaxis signs; high-risk immunosuppression |
Phrase Questions Well
Use neutral phrasing: “Any chest pain?” beats “You don’t have chest pain, right?” Follow a “yes” with the brief facts you need: onset, pattern, severity, triggers, and ties to the chief concern. Mark salient negatives that steer choices, like “no red, hot joint” in an arthritis visit.
Close The Loop
At the end, recap the handful of positives and the single most relevant negative per system you covered. Ask, “Anything else bothering you today that we did not touch?” Then move straight to the exam or plan so patients see the payoff from the questions.
How To Perform A Review Of Systems In Busy Clinics
Speed comes from preparation and structure, not from rushing the patient. Build a one-page ROS card for your specialty. Use intake forms to pre-screen, and then confirm the answers in your own words. Delegation is allowed; many clinics use team-based intake where staff or the patient fills a checklist that you verify. Older CMS rules described three levels of ROS for billing and listed 14 systems. That material still helps with teaching and shared language. See the 1995 CMS documentation guidelines for the classic definitions.
Office E/M coding moved to time or medical decision making in 2021, which removed ROS counts from level selection. That change did not erase clinical value. Keep the ROS lean, link it to decisions, and chart it because it safeguards care and communication. A quick primer on that coding shift sits on the AAFP site: office E/M coding change in 2021.
Calibrate Depth To The Setting
Primary Care: Start with the system tied to the visit and sweep two or three neighbors that could add clues. A blood pressure follow-up might include headaches, vision change, chest pain, shortness of breath, swelling, urination, and med side effects. Keep the rest for the annual visit.
Urgent Care: Use a narrow, high-yield pass with red flags built in. A sore throat screen might include fevers, cough, shortness of breath, drooling, neck swelling, and rashes. A sprained ankle screen might include numbness, weakness, color change, and calf pain.
Inpatient: Start broad on admission to set a baseline, then trim on daily rounds. Aim at new symptoms, device issues, bowel and bladder patterns, delirium signs, and pain control. Tie every added question to a change in the plan for that day.
Telehealth: Keep questions concrete, since you cannot check in person as easily. Ask about home readings if available, breathing at rest and with activity, fluid intake, urine output, and red flags that would prompt an in-person visit.
Link The ROS To The History Of Present Illness
A strong ROS reinforces the story, it does not replace it. When a symptom belongs in the history of present illness, keep the core details there, then capture short “pertinent positives” and “pertinent negatives” in the ROS for speed. Do not copy the same sentence into both sections. That habit creates conflicts and weakens trust in the note.
Pick Pertinent Negatives With Care
Choose negatives that actually change your next step. Chest pain with no shortness of breath, no exertional trigger, and no radiation tells a clearer story than a dozen unrelated “no” items. In a cough visit, “no fever, no hemoptysis, no weight loss” tells readers why you skipped a chest film today.
Document Clearly And Ethically
Use short, direct phrases. Avoid boilerplate that claims you reviewed systems you never asked about. If you use a form, say you reviewed it and covered positives face to face. If the sweep reached most systems, a single line such as “all other systems reviewed and negative” appears in many templates, but use it only when true and only after you documented enough detail to justify the statement. Older compliance guides explain when that line fits and stress accuracy over length.
Short Phrases That Work Well
Examples: “Resp: dry cough, no blood, no wheeze.” “CV: brief palpitations, no chest pain, no fainting.” “GI: heartburn nights, no black stool.” These are fast to read and align with how teams scan notes.
Note Phrases And What They Mean
| Phrase | Meaning | Tip |
|---|---|---|
| “All other systems negative.” | You asked about the remaining systems and heard no symptoms. | Use only if you truly screened the rest; avoid on focused visits. |
| “Denies red flag symptoms.” | You asked about specific danger signs and none were present. | Name the sign once to avoid vague wording. |
| “Reviewed patient checklist.” | You read a completed ROS form and confirmed entries. | State what you talked about; chart any changes in your words. |
| “Pertinent negatives noted.” | You selected salient “no” items that guided decisions. | Pick items tied to today’s concern, not a random list. |
Common Pitfalls And Safety Checks
Avoid double counting a symptom in the history and again in the ROS just to pad the chart. Do not copy a full negative ROS into a note with a positive in the same system; that mismatch creates audit risk and, and it confuses the next clinician. Watch for loaded topics that need a gentle pause, such as sexual health, substance use, mood, falls, and pain. Offer privacy, ask in simple words, and move on if the patient declines today.
Handling Sensitive Topics Smoothly
Use matter-of-fact language and offer choices. “Any new partners or unprotected sex?” “Any trouble cutting down on drinking?” “Any falls in the past year?” If the answer is yes, pivot to brief safety steps and a plan to return to the topic if time is tight.
Sample Script You Can Adapt
“I’m going to run a quick symptom check. Please say yes or no, and we’ll pause if anything needs detail. Fever, chills, or night sweats? Any change in weight or energy? Any vision changes or eye pain? Any hearing changes, nasal blockage, sore throat, or trouble swallowing? Any cough, shortness of breath, wheeze, or blood? Any chest pain, skipped beats, or swelling in the legs? Any heartburn, nausea, vomiting, belly pain, change in stools, or blood? Any burning or blood with urination? Any joint pain or swelling? Any new rashes or sores? Any headaches, weakness, numbness, or imbalance? Any mood change or trouble sleeping? Any heat or cold intolerance, thirst, or urination change? Any easy bruising or swollen glands? Any allergy flares or frequent infections?”
Template For Notes
ROS: Const: no fevers, no chills, unplanned 3-kg weight loss over 2 months. Eyes: no vision change. ENT: sore throat better, no trouble swallowing. Resp: dry cough, no blood, no wheeze. CV: brief palpitations, no chest pain, no fainting. GI: heartburn nights, no black stool. GU: no burning, no blood. MSK: knee stiffness mornings. Skin: no new rash. Neuro: no weakness, no numbness. Psych: waking at 3 a.m., no self-harm thoughts. Endo: heat intolerance. Heme/Lymph: bruises easily. Allergy/Immun: spring rhinitis, no recent infections. All other systems reviewed and negative where not listed.
Pediatric And Geriatric Tweaks
Pediatrics
Ask a parent for feeding, growth, fevers, rashes, sleep, stool, and urine. Add breathing rate with feeds, color change, rashes, and injuries. Teen visits work better with brief private time. Use simple, direct words and offer a chance to write answers if that helps.
Older Adults
Add falls, near-falls, appetite, weight change, memory slip, dizziness on standing, bowel and bladder control, hearing, vision, and pain. Screen for polypharmacy symptoms like lightheadedness, confusion, and constipation. Confirm who helps at home and any equipment in use.
When To Stop The ROS
Stop when more screening will not change today’s plan. A chest pain visit does not need a lengthy review of toenail issues. A dizzy patient with new neurologic deficits needs an exam and urgent steps, not a tour of every system. Good judgment beats long checklists.
Safety Net Lines
Offer clear return steps. Sample lines: “If you notice chest pain, trouble breathing, fainting, black stool, or new weakness, call now or go to the nearest emergency department.” “If symptoms grow or new ones appear, send a message or book a follow-up this week.” Seek help.
Teaching Points For New Clinicians
Practice reading a room: pace, tone, and pauses matter as much as the words. Keep one pocket card of high-yield screens per system. Memorize a tiny set of red flags that trigger same-day action. Learn one sentence that explains why you are asking about a sensitive topic. Close with a short recap so the patient hears the thread that connects the symptoms to the plan.
Quality And Compliance Notes
Clinical documentation should serve patient care first. Notes must reflect what you asked and what the patient said. Older billing guides still shape many templates, and you will see the 14-system list again and again because it gives teams a shared map. If you need a source that defines that list and the classic language, the ACC page linked above has it, and the CMS document quoted earlier shows the formal terms used in many policies.