Question 1

What is a Review of Systems (ROS)?

Accepted Answer

A Review of Systems (ROS) is a systematic inventory of body systems obtained through a series of questions to identify signs and symptoms. It is used by healthcare providers to gather comprehensive information about a patient's health status across different organ systems.

Question 2

What body systems are typically included in a ROS?

Accepted Answer

A comprehensive ROS typically includes constitutional symptoms, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin/breast), neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic systems.

Question 3

How many systems need to be documented for billing purposes?

Accepted Answer

For billing and documentation purposes, a problem pertinent ROS requires at least 1 system, an extended ROS requires 2-9 systems, and a complete ROS requires at least 10 systems to be documented.

Question 4

Can patients complete ROS forms themselves?

Accepted Answer

Yes, patients can complete ROS questionnaires or forms independently before their appointment. However, the healthcare provider must review and document the information as part of the medical record.

Question 5

What's the difference between ROS and physical examination?

Accepted Answer

ROS involves asking questions about symptoms the patient may be experiencing across different body systems, while a physical examination involves the provider's direct observation, palpation, and assessment of the patient's body systems.

Question 6

How does ROS relate to medical coding and billing?

Accepted Answer

ROS documentation is a key component of Evaluation and Management (E/M) coding. The extent of ROS documented (problem pertinent, extended, or complete) helps determine the appropriate level of service for billing purposes.

Question 7

Are there templates available for ROS documentation?

Accepted Answer

Yes, many electronic health record systems and medical organizations provide standardized ROS templates and checklists to help ensure comprehensive and consistent documentation across all relevant body systems.

Question 8

How long does a complete ROS typically take?

Accepted Answer

The time required varies depending on the method used and patient complexity. A comprehensive ROS questionnaire may take patients 10-15 minutes to complete, while provider-conducted questioning may take longer.

Question 9

What happens if a patient reports 'no' to all ROS questions?

Accepted Answer

If a patient denies all symptoms across the systems reviewed, this should still be documented as part of the ROS. The documentation should clearly indicate which systems were reviewed and that the patient denied symptoms.

Question 10

Can ROS information be updated during follow-up visits?

Accepted Answer

Yes, ROS should be updated at subsequent visits, especially for ongoing care. Providers typically focus on changes since the last visit and may perform a more targeted review based on the patient's current condition.

Question 11

Is ROS required for all types of medical visits?

Accepted Answer

ROS requirements vary depending on the type and level of service being provided. It is typically required for comprehensive examinations and higher-level E/M services, but may not be necessary for focused or problem-specific visits.

Question 12

How should positive ROS findings be documented?

Accepted Answer

Positive ROS findings should be clearly documented with specific details about the symptoms, including duration, severity, and associated factors. This information often leads to further questioning or examination of the affected system.

Question 13

What is the relationship between chief complaint and ROS?

Accepted Answer

The chief complaint identifies the primary reason for the visit, while ROS provides a broader systematic review of all body systems. ROS may reveal additional symptoms related to or separate from the chief complaint.

Question 14

Can electronic health records automate ROS documentation?

Accepted Answer

Many EHR systems offer automated ROS templates, patient portals for pre-visit completion, and smart forms that can streamline the documentation process. However, providers must still review and validate the information entered.

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