List systems reviewed, record key positives and negatives, link to the HPI, and write clear phrases that fit the patient’s story.
Documenting the review of systems step by step
Start near the chief complaint. Pull details that belong in the HPI, then sweep across other systems to catch related symptoms. Ask open questions first, then confirm with a few targeted prompts. Record what the patient reports today. Past issues stay in the past history.
Scope depends on context. A blood pressure check needs a brief screen. Chest pain needs a wider net. The 2023 E/M guideline update made code selection rest on MDM or time in most settings, so your note only needs a medically appropriate ROS. Still, the content should guide the plan and rule in or out key risks.
Write positives and pertinent negatives. Quote a few key phrases when they add clarity, like “worst headache” or “black stools.” Use standard terms so team members and coders read the same thing. Avoid long copy-pasted blocks that don’t fit the visit.
Keep privacy in sight. Only record what you need for this visit and follow the HIPAA minimum necessary standard. Sensitive facts that don’t change care can stay out of the ROS.
Core systems, common symptoms, and phrasing
| System | Common symptoms to record | Sample phrasing |
|---|---|---|
| Constitutional | fever, chills, night sweats, weight change, fatigue | No fever or chills; reports two weeks of fatigue and 2 kg loss. |
| Eyes | blurred vision, double vision, pain, discharge, redness | Blurry vision on near tasks; no eye pain or redness. |
| ENT | sore throat, congestion, ear pain, tinnitus, epistaxis | Nasal stuffiness and post-nasal drip; no sore throat. |
| Cardiovascular | chest pain, dyspnea on exertion, palpitations, edema, syncope | Intermittent chest pressure and brief palpitations; no syncope. |
| Respiratory | cough, sputum, shortness of breath, wheeze, pleuritic pain | Dry cough and mild exertional dyspnea; no wheeze. |
| Gastrointestinal | nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool | Crampy lower abdominal pain; no vomiting or GI bleeding. |
| Genitourinary | dysuria, frequency, urgency, hematuria, discharge | Burning with urination and urgency; no hematuria. |
| Musculoskeletal | joint pain, swelling, stiffness, back pain, myalgias | Aching knees after stairs; morning stiffness < 10 minutes. |
| Skin | rash, pruritus, new lesions, color change, wounds | Itchy papular rash on wrists; no open wounds. |
| Neurologic | headache, focal weakness, numbness, dizziness, seizures | Pulsing right-sided headache; no focal deficits or syncope. |
| Psychiatric | mood change, anxiety, sleep change, hallucinations | Low mood and poor sleep; no hallucinations. |
| Endocrine | heat/cold intolerance, polyuria, polydipsia, hair change | Cold intolerance this winter; no polyuria. |
| Heme/lymph | easy bruising, bleeding, lymph node swelling | No bruising or bleeding; denies lymph node swelling. |
| Allergy/immunologic | seasonal symptoms, food reactions, frequent infections | Seasonal sneezing each spring; no food reactions. |
Review of systems documentation examples that work
These short samples show how the ROS supports the plan without bloating the note. Tailor the phrasing to the visit and the patient’s words.
Chest pain visit
HPI link: Pressure mid-sternal, 10 minutes at rest yesterday, no radiation, relieved by rest. Risk factors: HTN, smoker.
ROS: Cardiovascular: chest pressure as above; brief palpitations during pain; no syncope. Respiratory: mild dyspnea during episode; no cough or wheeze. GI: no reflux symptoms, no vomiting. Neuro: no focal weakness, no slurred speech. Psych: anxious since event, sleep poor.
Headache visit
HPI link: New, right-sided throbbing, started two days ago, photophobia, improved with sleep, worse with noise, no head trauma.
ROS: Neuro: throbbing headache, light sensitivity, no vision loss, no limb weakness. ENT: no sinus pressure, no sore throat. GI: mild nausea, no vomiting. GU: regular menses, last period two weeks ago. Constitutional: no fever.
Cough and fever
HPI link: Non-productive cough for five days; fever peaked at 38.6°C yesterday; three sick contacts at home.
ROS: Respiratory: dry cough, short of breath with stairs, no chest pain. ENT: nasal congestion and scratchy throat. GI: no vomiting or diarrhea. Skin: no rash. Constitutional: fever yesterday, chills overnight, low appetite today.
Abdominal pain
HPI link: Crampy right-lower pain for 12 hours, worse with walking, no prior episodes.
ROS: GI: localized right-lower pain, no melena, last BM yesterday. GU: no dysuria or hematuria, LMP three weeks ago. Const: no fever. Neuro: no dizziness.
Diabetes follow-up
HPI link: Type 2 DM with rising home readings; lifestyle change stalled.
ROS: Endocrine: polydipsia and frequent urination last week. Eyes: no vision change. Neuro: no numb feet. CV: no chest pain or leg swelling. Skin: no foot wounds.
How to keep the ROS accurate, concise, and useful
Use structure that fits your EHR, then add free text for clarity. Avoid contradictions with the HPI. If the HPI says “daily cough,” the ROS should not say “no cough.” If you reviewed a patient form, state that you reviewed it and updated it during the visit.
The CMS page on E/M visits explains the move to MDM or time. That change frees you from counting bullets. It does not change the need for clear clinical notes. In short visits, a focused ROS tied to the problem is enough. In complex cases, expand the list and note key negatives that shape risk.
Tips that save time without cutting corners
- Keep a short starter for common complaints, then edit in front of the patient.
- Write “as above” to link the ROS to details already covered in the HPI.
- Use checkboxes for quick negatives, then add one line that captures the story.
- Skip boilerplate lines like “all systems negative” unless you truly asked each system that day.
- Never paste an old ROS that no longer matches the visit.
Shortcuts that stay safe
Safe shortcuts share two traits: they are true for this visit and they add context. Examples: “All other systems reviewed and negative related to chest pain workup today” or “Except as in HPI, no additional respiratory or cardiac symptoms reported.” These lines tell the reader what you checked and why.
Common mistakes and quick fixes
Mixing exam with ROS: Breath sounds and heart rate belong in the exam, not the ROS. Fix by moving those lines to the exam section.
Vague negatives: “Denies GI issues” is too broad. Better: “No nausea, no vomiting, no blood in stool.” Pick the negatives that change risk.
Missing context: “No weight loss” can mean little without a time frame. Add one: “No unintentional weight change this month.”
Copying forward: Old templates save time but can mislead. A weekly asthma check should not carry over last month’s “no cough” when the HPI states daily cough today.
Privacy gaps: Notes can grow past what you need. Only record details that help the plan and protect PHI as required by HIPAA.
Template phrases you can adapt
Drop these into your EHR and tune them during the visit. The aim is a short list that tracks with the plan.
- Problem-focused ROS: “Const: no fever or chills. Resp: dry cough x 5 d, mild SOB with stairs. CV: no chest pain. ENT: scratchy throat.”
- Extended ROS: “Const: fatigue this week. CV: intermittent palpitations; no syncope. Resp: DOE, no wheeze. GI: reflux after meals; no vomiting.”
- Complete ROS (pre-op): “Const: no fever/chills. Eyes: wears glasses, no acute change. ENT: no sore throat. CV: no chest pain. Resp: no SOB. GI: regular BM, no blood. GU: no dysuria. MSK: mild knee pain. Skin: no wounds. Neuro: no focal deficits. Psych: mood stable. Endo: no polyuria/polydipsia. Heme: no bruising. Allergy: seasonal sneeze only.”
Template safety check table
| Common phrase | When it works | Risk and upgrade |
|---|---|---|
| “All systems reviewed and negative.” | Annual visit with full review truly performed and documented that day. | Over-claiming review. Safer: “All other systems reviewed today and negative unless noted.” |
| “ROS per patient form.” | Form completed today and reviewed in the room with updates. | Stale forms. Add: “Reviewed and updated with patient during today’s visit.” |
| “As above.” | When the HPI already holds the symptom detail. | Loss of context. Add a short clause, eg., “As above, exertional chest pressure.” |
| “Denies GI symptoms.” | Quick note when GI review is not central to the visit. | Too broad. List two or three key negatives that shape risk. |
| “No neurologic symptoms.” | Post-vasovagal event with complete recovery and normal exam. | Missed red flags. Add: “No focal weakness, no numbness, no speech change.” |
Maintaining clarity across teams
Clear ROS language helps consultants, coders, and patients who read their notes. Use short sections, standard system names, and time frames. Be consistent visit to visit. When a patient moves across settings, your ROS should still read the same way.
Audit-proof habits
- Note who supplied the history when it isn’t the patient.
- State if an interpreter was present and the language used.
- Tie key negatives to risks you are weighing.
- Avoid contradictions between triage text, HPI, ROS, and exam.
- Document review of external records when they shape the ROS.
When less is more
Short visits do not need a long ROS. Pick the systems that guide the plan and explain why you checked them. A single line can carry weight when it points to action, such as testing, imaging, or a change in therapy.
From checklist to clear story
Checklists keep you from missing a system. The note still needs a story. Bring the headline signs to the top, keep minor items brief, and flag any red flags. The best ROS reads like a crisp snapshot that backs your plan.
How to document the ROS for special cases
Pediatrics: Add feeding and hydration, diaper counts, school performance, and behavior shifts. Ask a caregiver for details and record who gave the history. If the child answers, quote short phrases that show their voice.
Geriatrics: Screen for falls, memory change, incontinence, appetite change, and medication effects. If a caregiver offers input, state that you heard both views and record any gaps.
Prenatal care: Track nausea, emesis, vaginal bleeding, fluid leak, contractions, urinary symptoms, headaches, vision change, RUQ pain, swelling, and fetal movement as weeks advance. Note red flags clearly.
Telehealth: Say which parts came from patient report and which came from home devices. If audio-only, avoid exam words in the ROS and stay clear on what was reported.
Phrases that flag red alerts
Some words should stand out in every chart. Highlight them in the ROS and link them to the plan so no one misses the signal.
- Chest pain with dyspnea, diaphoresis, or syncope.
- Thunderclap headache or new neuro deficit.
- Black stools, coffee-ground emesis, or maroon stool.
- Fever with neck stiffness or confusion.
- Sudden vision loss, jaw claudication, or new temporal pain in older adults.
- Unintentional weight loss with night sweats.
- Shortness of breath at rest or orthopnea with leg swelling.
Abbreviations that stay clear
Shortcuts help as long as the meaning stays obvious. Pair a short code with a plain phrase the first time in a note, then use the code.
- SOB: shortness of breath.
- DOE: dyspnea on exertion.
- PND: paroxysmal nocturnal dyspnea.
- N/V/D: nausea, vomiting, diarrhea.
- LMP: last menstrual period.
- PO: by mouth, if diet matters to the symptom.
Skip local slang that won’t travel well across teams. Keep the ROS readable to any clinician who picks up the chart.
Review of systems documentation examples that teach clarity
Short URI visit: “Const: low energy today. ENT: congestion and scratchy throat. Resp: dry cough; no dyspnea. GI: no vomiting, no diarrhea.”
Pre-op clearance: “Const: no fever/chills, good exercise tolerance. CV: no chest pain or edema. Resp: no SOB, no wheeze. GI: no reflux, regular BM. GU: no dysuria. Neuro: no deficits. Heme: easy bruising denied.”
Back pain: “MSK: lumbar ache after lifting; no leg weakness. Neuro: no numbness, no saddle anesthesia, no bladder issues. Const: no fever.”
Syncope: “Neuro: brief loss of consciousness after standing; no seizure activity. CV: palpitations last week; no chest pain today. Resp: no SOB. GI: no blood loss.”
Quality checks before you sign
- Does the ROS match the HPI story and the plan?
- Are the key negatives tied to the risks you weighed?
- Is every line true for this visit and date?
- Would a colleague know what you asked and why?
- Did you stay within the HIPAA minimum necessary rule?
When those answers land in the right place, your documentation supports care and stands up to review.