Scribe Series: ROS

Hello Again.

This week I’m going to go over all things ROS, or Review of Systems. If you’ve been following along with the prior posts in this series, Scribe Series: History & Outline of Charting and Scribe Series: HPI, then you know that ROS is the last part of the subjective portion of the chart. 

I won't make this one crazy long, as this portion of the chart is one of the easiest things to get down!

The ROS is made up of 9 body systems, and is usually a list or plus/minus checkbox of symptoms the patient is having. Depending on what speciality or your provider preference, these will include associating symptoms and chief complaint from the HPI. Otherwise, the ROS serves to help rule out other systems that could be involved with the complaint or concern of your patient. It is also used to see if there are other systems involved in potentially other problems. Lastly, depending on how many different systems you ask complaints from, you can bill differently. 

Since we live in a world now where insurance companies can run how some hospitals will function, this is a point that gets hit hard when you are learning to scribe.

As a scriblet, your whole job is to make sure that we are charting the correct amount of things that you provider is doing. If your provider does it, a scribe needs to chart it. That’s how the hospital gets paid and how you will subsequently get paid. You have a job as a scribe because providers don’t either a) remember to chart what they did or b) don’t want to put in the effort to chart every little thing they did. 

Now, this doesn’t mean you can just put whatever you want and bill for it. That is a big no-no. You will get fired (and rightfully so). But, a scribe is there to make sure the hospital and health system gets reimbursed for all of the services that the provider did for the patient. Because charting is a lot of extra work. And that the degree of charting wasn’t required 10+ years ago. Thus, you have a job as a scribble!

Think of it this way: you wouldn’t go to a mechanic and expect to get your oil changed and tires swapped without a service fee and paying for the parts/products used. 

It’s the same way in medicine. You are going to pay for the time and expertise of the provider along with any additional tests or procedures (that would take additional time or expertise of the physician) if needed. So if you went in for a routine checkup but also wanted a steroid shot in your knee, you would pay for the routine checkup expertise & time, and the additional time (out of the physicians day) and the needed supplies for the knee injection.

You see where I’m going with this?

9 Systems:

As I mentioned above, there are 9 systems that the ROS falls under. You can have some slight differences depending on the specialty that you want to tweak it to, or how the provider will want it split up. But majority speaking, they are fairly consistent throughout. You will see the system (or an example of a system) and then examples of what would go under that system in the ROS. Remember, these are SYMPTOMS. Not physical exam findings (usually). There are some caveats with that though.

General:  This section is your overall general complaints. They affect a lot of different systems and are not particularly unique to just one system. Examples of what is included under here:

• Fevers
• Chills
• Weakness
• Fatigue
• Appetite changes
• Diaphoresis or night sweats
• Weight changes

HEENT: Stands for Head, eyes, ears, nose, and throat. Example symptoms included here are:

• Head injuries
• Eye pain
• Changes in vision
• Diplopia/double vision
• Redness/erythema (eyes or throat)
• Discharge (eyes or ears)
• Dry eyes
• Hearing loss
• Ear pain
• Tinnitus/ringing in your ear
• Nosebleeds/epistaxis
• Anosmia/loss of smell
• Difficulty breathing through the nose
• Throat pain
• Painful swallowing (odynophagia)
• Difficulty swallowing (dysphagia)
• Swelling of throat
• Hoarsness
• Dental pain
• Mouth sores

*Neck: This could be lumped into HEENT if you didn’t want to create another section. But, if you are doing a targeted ROS you can pull this one out. In general there are not a lot of complaints to put here.

• Enlarged lymph nodes
• Stiff neck
• Goiter

Chest/Respiratory: Usually cardiac symptoms and respiratory symptoms are lumped together for the ROS. But they are separate for the physical exam.

• Chest pain
• Palpitations/change in heart rate
• Shortness of breath/dyspnea
• Cough
• Sputum production
• Hemoptysis (coughing up blood)
• Leg swelling

GI: This includes all things gastrointestinal (or what GI stands for).

• Abdominal pain
• Nausea
• Vomiting
• Bloody vomit/hematemesis
• Diarrhea
• Hematochezia
• Melena
• Constipation
• Rectal pain
• Hemorrhoids

MSK: All things musculoskeletal. So much can go under here.

• Arthralgias
• Myalgias
• Stiffness
• Any particular/specific muscle, joint, or limb pain.
• Falls

GU: This stands for genito-urinary. Anything related to the urinary system OR the genitals is put here.

• Frequent urination
• Urgency
• Dysuria
• Incontinence
• Hematuria
• Any change in menses
• Vaginal/penile discharge
• Vaginal/penile pain
• Lesions
• Change in libido

Neuro/psych:  Usually neuro is by itself. Psych is not usually added unless there is a complaint of it. But you can also lump it together like I have here.

• Headache
• Dizziness
• Gait changes
• Seizures
• Tremors
• Paresthesias/tingling
• Speech changes
• Fainting/Loss of consciousness 
• Suicidal ideation
• Depression
• Homicidal ideation
• Hallucinations

Skin: This one is pretty self explanatory.

• Erythema/redness
• Rash
• Swelling
• Itching
• Hives
• Nail changes

Endocrine/Vascular:

• Easy bruising/bleeding
• Gums bleeding
• Blood clots
• On Anti-coagulation therapy
• Fatigue
• Polydipsia
• Polyuria

How Does an ROS look?

There are a couple of different ways an ROS can look. It all depends on what system you use, your provider’s preference, or what the hospital system dictates. Some of these options include:

• It could be +/- checkbox of symptoms under each system. 
• It could be a list that is either pre-made and brought in by a template that you change, or you type it out yourself. Again, it is a list of symptoms under each system
• The clinic you work at could have a questionnaire that the patient fills out. You can use this to fill out a chunk of it. The rest of it you need to add/modify based on the HPI.
• Some ROS’s you cannot do. These tend to be statements explaining why. See below. 
• Some ROS’s can be small if it is an acute setting or in the setting of an urgent care/minor care.

Exceptions to filling out the ROS:

There are certain cases where you simply cannot fill out an ROS. OR, someone else is needed to provide history for your patient. When this happens, you need to state WHY you cannot fill this out or why the patient themself are not providing history. Reasons being:

• History provided by parent or legal guardian (if a small child; they could be great historians or poor historians)
• History limited due to intoxication (usually when someone is super drunky drunk)
• History limited due to LOC (or loss of consciousness. Could be they are conked out from drugs or alcohol, trauma, or are very sick)
• History limited due to language barrier
• History limited due to mental capacity/dementia/etc. 

In your EMR, there will usually be a separate drop down or an area where you can choose from some options or type in why you cannot obtain a complete history. This goes both for the HPI and ROS sections.

When do they ask the ROS?

Providers will usually ask this at the very end of them gathering the HPI information. If you are in the ED or family medicine, this is a pretty easy time to spot when they are asking it: it doesn’t really flow with the rest of how they are doing it. (In some specialities, they don’t really need to ask a huge list from the ROS, so the questions they ask for this to be filled out are less obvious. Or they use a questionnaire to get the rest of the ROS.)

They tend to list a lot of symptoms (each provider has their own symptom order/system order they ask questions in) after obtaining all of the information they wanted. This again, is to serve to rule out other potential differential diagnoses, but your provider likely already asked majority of what they wanted in the HPI. 

So if your provider already asked what they wanted earlier in the conversation, that means that they are asking for overall completeness for the patient visit, evaluation, and lastly charting (which is really very low on provider’s list of things to take care of by the way!).

Last Bit of Advice:

As a scribe, your providers can be a wee bit of jerks about this. Over the 6 years I scribed, a chunk (and I truly mean more than I want to count) of providers will honestly try to talk super fast to see if you can catch up. 

Not joking.

How do you take care of this?

One is shorthand. But you have to be able to read your shorthand if you are going to use it! Most of the time, the symptoms they list off in a super fast order the patient won’t be able to register what symptom it is or say no. The ones they say yes on will give you some time as the provider will have to clarify (or explore) why they said yes. 

The second way to go about this, is if you work with your provider long enough, you already know their order and symptoms they will ask! If using EPIC, where they have .dotphrases, you can make one and simply pull it in your chart. Then all you have to do is change all those negative symptoms to a positive one if your patient answers yes. 

If you don’t have a quick link for something like this in your EMR, then I would usually only type down the positive symptoms since I already knew all of the things the provider would ask. That way I wouldn’t miss any thing in the room. I could then go back in later and add all the negative ones to my chart when finishing/cleaning up my chart.

You could also put a “y/yes” or “+” and list the positive symptoms and a “n/no” or “-” for negative symptoms and go back and clean up that section later as well. Because again, your shorthand (such as using “y”) will likely not be able to be understood by other healthcare providers.

Otherwise, if you have a checkbox system (super duper easy!), you just have to click what was asked and if it was positive or not.

So yea, that’s basically it for the ROS. Take this one as an easy victory when learning how to chart!