ROS Checklist

April 22nd, 2009 - Rikki Runyon

Categories: Audits/Auditing Coding Compliance CPT^® Coding Documentation Guidelines Evaluation & Management (E/M) Electronic Medical Records (EMR/EHR) Medical Records Medicare Practice Management Specialty Coding

Review of Systems

CHECKLIST:

-General-

? Weight loss or gain ? Fatigue ? Fever or chills

? Weakness ? Trouble sleeping

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-Skin-

? Rashes ? Lumps ? Itching

? Dryness ? Color changes ? Hair and nail changes

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-Head-

? Headache ? Head injury

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-Ears-

? Decreased hearing ? Ringing in ears (tinnitus)

? Earache ? Drainage

-----------------------------------------------------------------------------------

-Eyes-

? Vision ? Glasses or contacts

? Pain ? Redness ? Blurry or double vision

? Flashing lights ? Specks ? Glaucoma

? Cataracts ? Last eye exam

-----------------------------------------------------------------------------------

-Nose-

? Stuffiness ? Discharge ? Itching

? Hay fever ? Nosebleeds ? Sinus pain

-----------------------------------------------------------------------------------

-Throat-

? Teeth ? Gums ? Bleeding

? Dentures ? Sore tongue ? Dry mouth

? Sore throat ? Hoarseness ? Thrush

? Non-healing sores ? Last dental exam

-----------------------------------------------------------------------------------

-Neck-

? Lumps ? Swollen glands

? Pain ? Stiffness

-----------------------------------------------------------------------------------

-Breasts-

? Lumps ? Pain ? Discharge

? Self-exams ? Breast-feeding

-----------------------------------------------------------------------------------

-Respiratory-

? Cough (dry or wet, productive) ? Sputum (color and amount)

? Coughing up blood (hemoptysis) ? Shortness of breath (dyspnea)

? Wheezing ? Painful breathing

-----------------------------------------------------------------------------------

-Cardiovascular-

? Chest pain or discomfort ? Tightness ? Palpitations

? Shortness of breath with activity (dyspnea)

? Difficulty breathing lying down (orthopnea) ? Swelling (edema)

? Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal Dyspnea)

-----------------------------------------------------------------------------------

-Gastrointestinal-

? Swallowing difficulties ? Heartburn ? Change in appetite

? Nausea ? Change in bowel habits

? Rectal bleeding ? Constipation ? Diarrhea

?Yellow eyes or skin (jaundice)

-----------------------------------------------------------------------------------

-Urinary-

? Frequency ? Urgency ? Burning or pain

? Blood in urine (hematuria) ? Incontinence

? Change in urinary strengt

-----------------------------------------------------------------------------------

-Genital-

Male-

? Pain with sex ? Hernia ? Penile discharge

? Sores ? Masses or pain

? Erectile dysfunction ? STD’s

Female-

? Pain with sex ? Vaginal dryness ? Hot flashes

? Vaginal discharge ? Itching or rash ? STD’s

-----------------------------------------------------------------------------------

-Vascular-

? Calf pain with walking (Claudication) ? Leg cramping

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-Musculoskeletal-

? Muscle or joint pain ? Stiffness ? Back pain

? Redness of joints ? Swelling of joints ? Trauma

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-Neurologic-

? Dizziness ? Fainting ? Seizures

? Weakness ? Numbness ? Tingling

? Tremor

-----------------------------------------------------------------------------------

-Hematologic-

? Ease of bruising ? Ease of bleeding

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-Endocrine-

? Head or cold intolerance ? Sweating ? Frequent urination (polyuria)

? Thirst (polydypsia) ? Change in appetite (polyphagia)

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-Psychiatric-

? Nervousness ? Depression ? Memory loss

? Stress

###

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