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Old 10-01-2012
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Question Listing Systems instead of Symptoms in ROS

to save time & space in exam can we write in patient's note that

patient has no pulmonay, cvc , git & neuro symptoms other than those mentioned earlier

instead of

patient has no shortness of breath, wheezing, cough, fever, palpitations, nausea, vomiting, constipation, diarrhea, headache, tingling sensation, fatigue.
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Old 10-01-2012
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You are referring to the Review of Systems (ROS).

In (ROS), it's wise to mention only the pertinent negatives and positives

For example; patient presented with presented with sore throat and fever then your ROS should like this
ROS: No chest pain, SOB, abdominal pain, headache. Cough was there as mentioned in HPI.

You don't need to mention No urinary symptoms, No GI symptoms, ...bla bla, just mention what's relevant to your case. If the same case for example has been taken antibiotic then it's wise to mention also No diarrhea for example.

Certainly do not say; No GI, No CVS, No Pulmonary symptoms (such generalization is not good and they will downgrade you for it)

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The above post was thanked by:
drssbaz (10-02-2012), imgaspirant (10-01-2012), Lotsahope (10-01-2012), RicMan (10-09-2012)



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