Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems

[secondmedicalop]

Individual Systems of the Review of Systems

The individual systems of the Review of Systems (ROS) are:

1. Constitutional Symptoms
2. Eyes
3. Ears, nose, mouth, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/lymphatic
14. Allergic/immunologic

As you can see, there are 14 recognized individual systems for the ROS. It is enough to identify (positively or negatively) a sign or symptom in the individual system so that it counts towards the number of systems being evaluated. The system directly related to the problem mentioned in the HPI has to be present.

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed March 30, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems”. SMO Blog (blog). March 30, 2020. https://hive.blog/hive-122108/@secondmedicalop/clinical-documentation-improvement-series-17-evaluation-and-management-documentation-2-individual-systems-of-the-review-of

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Substance Dependence and Associated Conditions.

- Clinical Documentation Improvement Series #7. Inpatient versus Observation

- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”

- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...

- Clinical Documentation Improvement Series #10. Documenting Pneumonia

- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…

- Clinical Documentation Improvement Series #12. Documentation of Acute Kidney Failure

- Clinical Documentation Improvement Series #13. Documenting Liver Failure

- Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1

- Clinical Documentation Improvement Series #15. General Advise (Tip #2)

- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

Picture downloaded from istockphoto.com under a standard license Author: Dragonimages