REVIEW OF SYSTEMS (ROS)

The review of systems is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

• Constitutional (e.g., temperature, weight, height, blood pressure) 

• Eyes 

• Ears, nose, mouth, throat 

• Cardiovascular 

• Respiratory 

• Gastrointestinal

• Genitourinary

• Musculoskeletal 

• Integumentary (skin and/or breast) 

• Neurological

• Psychiatric 

• Endocrine 

• Hematologic/Lymphatic 

• Allergic/Immunologic

There are three levels of ROS:

1. Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system—psychiatric—is reviewed: 

• CC: Depression. 

• ROS: Positive for appetite loss and weight loss of 5 pounds (gastrointestinal/constitutional).

2. Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems—constitutional and neurological— are reviewed:

• CC: Depression. 

• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early morning wakefulness.

3. Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

• CC: Patient complains of depression. 

• ROS:

a. Constitutional: Weight loss of 5 lb over 3 weeks 

b. Eyes: No complaints 

c. Ear, nose, mouth, throat: No complaints

d. Cardiovascular: No complaints

e. Respiratory: No complaints 

f. Gastrointestinal: Appetite loss 

g. Urinary: No complaints 

h. Skin: No complaints 

i. Neurological: Trouble falling asleep, early morning awakening 

j. Psychiatric: Depression and loss of sexual interest

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

There are three basic history areas required for a complete PFSH: 

1. Past medical/psychiatric history: Illnesses, operations, injuries, treatments

2. Family history: Family medical history, events, hereditary illnesses 

3. Social history: Age-appropriate review of past and current activities 

The data elements of a textbook psychiatric history, listed below, are substantially more complete than the elements required to meet the threshold for a comprehensive or complete PFSH:

• Family history 

• Birth and upbringing 

• Milestones 

• Past medical history

• Past psychiatric history

• Educational history 

• Vocational history 

• Religious background 

• Dating and marital history

• Military history 

• Legal history 

The two levels of PFSH are:

1. Pertinent, which is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document one item from any of the three history areas. In the following example, the patient’s past psychiatric history is reviewed as it relates to the current HPI: 

• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac. Episode lasted 3 months.

2. Complete. At least one specific item from two of the three basic history areas must be documented for a complete PFSH for the following categories of E/M services:

• Office or other outpatient services, established patient 

• Emergency department 

• Domiciliary care, established patient 

• Home care, established patient 

At least one specific item from each of the three basic history areas must be documented for the following categories of E/M services:

• Office or other outpatient services, new patient 

• Hospital observation services 

• Hospital inpatient services, initial care 

• Consultations 

• Comprehensive nursing facility assessments

• Domiciliary care, new patient 

• Home care, new patient