Review of Systems (ROS)

Definition and Purpose

• Goldman-Cecil Medicine states: "The review of systems elicits symptoms or signs not covered or overlooked in the history of the present illness." It is more efficient when questions are restricted to a specific time period (e.g., "shortness of breath this past week") or using a previsit questionnaire.
• Tintinalli's Emergency Medicine notes: ROS "can be accomplished in a more structured manner than the rest of the interview and sometimes can help redirect the patient... Specific targeted yes or no questions... can help hone the differential diagnosis."

Types of ROS (CMS Classification)

Note: Under 2023 CMS E&M guidelines, ROS is no longer a required billing element for ED visits - billing is now driven by medical decision-making (MDM) or total time. A focused ROS remains clinically valuable, however.

The 14 CMS-Recognized Organ Systems

1. Constitutional - fever, chills, weight loss/gain, fatigue, night sweats
2. Eyes - visual acuity, diplopia, discharge, pain, vision changes
3. Ears, Nose, Mouth, Throat (HEENT) - hearing, tinnitus, congestion, sore throat, difficulty swallowing
4. Cardiovascular - chest pain, palpitations, tachycardia, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, syncope
5. Respiratory - cough, hemoptysis, wheezing, dyspnea, pleurisy
6. Gastrointestinal - appetite, nausea/vomiting, dysphagia, odynophagia, constipation, diarrhea, change in bowel habits, melena, hematemesis, hematochezia, bloating, jaundice, abdominal pain
7. Genitourinary - urinary frequency, nocturia, dysuria, hematuria, changes in stream force, sexual dysfunction
8. Musculoskeletal - joint pain/swelling, muscle weakness, fractures
9. Integumentary (Skin/Breast) - rashes, lesions, lumps
10. Neurological - headache, dizziness, seizures, syncope, weakness, numbness, tingling, gait disturbance, memory/cognitive change, speech problems, vision, hearing
11. Psychiatric - mood changes, anxiety, depression, hallucinations, sleep disturbance, suicidal ideation
12. Endocrine - polyuria, polydipsia, polyphagia, heat/cold intolerance, thyroid symptoms
13. Hematologic/Lymphatic - easy bruising, bleeding, lymphadenopathy, anemia symptoms
14. Allergic/Immunologic - seasonal allergies, recurrent infections, drug reactions

System-by-System Highlights

Constitutional

Head / Neurological

• Cognition, personality, and mood change
• Hallucinations
• Seizures and impairments of consciousness
• Orthostatic faintness, headaches
• Special senses (vision, hearing)
• Speech and language function
• Swallowing difficulties
• Limb coordination, involuntary movements
• Strength, sensation, gait and balance
• Sphincter, bowel, and sexual function

Eyes, Ears, Nose, Throat

Cardiovascular

Respiratory

Gastrointestinal

Psychiatric ROS

Special Populations

• Pediatric patients (Harriet Lane Handbook): ROS should include developmental milestones, pregnancy course, prenatal exposures, perinatal history, and type of conception.
• Neurologic patients: Multiorgan involvement characterizes several neurologic disorders (vasculitis, sarcoidosis, mitochondrial disorders, storage diseases) - a full systems review is essential.
• Oncology/Melanoma staging: ROS is a key part of staging workup for melanoma and other cancers - constitutional, respiratory, neurologic, hepatic, musculoskeletal, GI, and skin systems all queried.

Documentation Tips

• A positive finding should be documented with details (onset, character, severity, duration, associated symptoms).
• Negative findings ("denies") are documented as pertinent negatives.
• The phrase "all other systems reviewed and negative" is acceptable shorthand for non-pertinent systems after documenting specific positive/negative findings.
• The ROS is based solely on subjective patient report - it is distinct from the physical examination.