premedical jobs – We're All Med Here

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!

Scribe Series: HPI

Hello again.

I thought today I would further break down each section of a medical chart. In last week’s post “Scribe Series: History & Outline of a Chart“, I broke down the SOAP note format and each section of the chart with a brief overview. Today I want to go more in-depth on the HPI.

Now remember from last week’s post, the HPI (or history of present illness) is the story that the patient is presenting for. Presenting is a fancy term for why they showed up to be seen. This is going to tell you why they are here and all the symptoms they have. You can then use this information to either narrow down and diagnose a problem, or just confuse yourself even more.

If you are writing this from a scribe point it will take you some time to not be confused. In the scribe role, you are in the process of learning how to chart, take information, listen and type, write it into a story, and change everything from lay-mans terms to medical jargon. But if you are on the medical side, as in taking the history yourself (say as a medical student), this is your chance to figure out what your patient has and how to take care of them.

Where does the HPI go?

I also mentioned this in the post prior to this one. But the HPI goes right under the chief complaint, at the very beginning of the chart. If you remember from the last post, the HPI is part of the subjective portion of the chart is the patients’ story. What they are experiencing, them recanting the order (if they can do this) in which things occurred, what they noted as odd or new to them, what hasn’t changed, etc. If they can’t put things in a longitudinal order, it is your job to somewhat figure it out as it may help you decide further what your patient has or how long they’ve had it. It will also greatly help when writing your note (but not nearly as important).

Because we first need to know why someone came in before we can assess them and help them, this is why it is at the beginning of the chart. Again, the SOAP note acronym not only designates what each section is and how to remember it, but what order it is in. Telling us the story of why someone came in will help lead us through this encounter and how to help take care of them.

Elements That make up the HPI

There are 8 fundamental questions that can be answered to make up the HPI. You don’t need all 8 to form a HPI, but the more that you have, the more information you can gather to fill out your story. When learning how to scribe you will have to know all of the elements and how to identify them. This is to help you understand the elements of the chart itself. Once you pass scribe training you will never really have to classify your HPI by the elements that comprise it.

As a medical student or PA/NP student, you are all learning how to ask different questions to your patient. All of the questions that you learn to ask revolve around the elements of the HPI. Again, you don’t technically have to identify them outside of your first lecture/quiz on it. But, the you basically already know what element it is because this is the reason why you are asking the questions in the first place.

The elements are …

Onset
Location
Duration
Character (can also be called quality)
Aggravating Symptoms
Alleviating Symptoms
Associated Symptoms
Radiation
Timing
Severity

Technically, the 3 A’s are all part of 1 element. But it’s easier to split them up than when first learning them.

The acronym we learned was OLDCAAARTS.

This is the acronym we use as medical students at our school to remind ourselves of what to ask when we are in our SP encounters (actors who are playing patients in scenarios) and likely when we start seeing patients in our rotation years. But pick an acronym that you will remember.

Example questions of elements…

When did your pain start? When did you first notice symptoms? (asking onset)
Where is the pain located? (location)
How long did the episode or do symptoms last? (duration)
Can you describe the pain? Is it sharp, stabbing, dull, squeezing, etc? (character or quality)
What makes it better? What makes it worse? (asking alleviating and aggravating factors)
What other symptoms have you noticed with this? Do you think these symptoms are related? (associated symptoms)
Does the pain travel anywhere? (radiation)
When do you notice the symptoms? Is it more in the morning/night? Is it when you are doing a certain activity? etc. (timing)
On a pain scale from 1-10, with 1 being normal/no pain at all and 10 being your arm was chopped off/you were giving birth, what do you rate your pain currently? At its worse? At its best? (severity)
- We only ask severity if it is a pain complaint. Otherwise, this element does not fit! You also want a reference of the pain scale so your patient knows how to rate their pain accordingly. Some patients are very accurate with their pain scale rating. But again, this is subjective, so some people can be much more dramatic about their pain or downplay their pain. You also want to give them the scale based off their gender. A guy is much more likely to envision 10/10 pain when their arm or leg gets chopped off. A woman is more likely to give a 10/10 pain with child-birth or labor.

Exceptions to writing a complete hpi:

There are times where you simply cannot get a full history or a good history. In times of this, you need to explicitly state why you cannot obtain a good history. Examples include:

History limited due to guardian account.
History limited due to language barrier
History limited due to dementia/mental capacity
History limited due to incapacitation/LOC (loss of consciousness)
History limited due to intoxication

On the flip side, if you have family members translating for them, or if they are a child and the parent has been able to capture a good history/observation of the child, or something of this sort, you also need to explain this. It looks something like this:

History was obtained from the child’s father.
History was obtained from the grand parents of the child.
Assistance in obtaining history came from the patient’s son/daughter/family members.
History was obtained via a translator. Patient speaks [insert language here] as their native language.
ASL translator present to assist in obtaining history.

You get the idea.

Why is the HPI So hard to write?

There are many, many reasons for this. I’ve seen new scribes struggle with many different aspects making it harder for them to learn, and I’ve seen some only struggle with one or two. It’s definitely harder to write it when you aren’t asking the questions and you don’t have any idea why certain parts of the history make sense together and others don’t. Or even the fact that one symptom could be associated with 200 different medical conditions.

I’ve compiled a few of the more common ones that either I, myself have struggled with when learning how to write the HPI or the new scribbles I would train would have difficulty with.

⇒ The biggest thing is learning how to listen and type. You are all of a sudden having to listen to a conversation and type down what you hear. Either word for word or be able to synthesize a few words together to make a coherent sentence. Oh man, this is one of the largest struggles that I see.

How do you improve this? Practice. Sit your butt in front of a television. Put on a kids show and just start typing. Don’t worry about spelling or grammar mistakes. Just type. Start teaching your brain how to move your fingers as fast as you are hearing the words. Kids shows are slower in speech, and are easier for your brain to start with. You have to also train your brain to not try to process what you are hearing necessarily. You just want to write what you hear.

You can then progress to a sitcom which is more typical of the speech speed you will hear. Got roommates? Type their conversations that they have with someone. Sit in a coffee shop or on campus and listen to a nearby conversation. Live with your parents or siblings? When they are having conversations (or fights, that one is just fun to do) type it down. Get in the habit of typing. If you want a super big challenge go for commercials.

⇒ You are learning to condense 2 other people talking (doctor and patient) in an order that is not chronological/doesn’t always make sense. You are having to take this jumbled conversation and turn it into coherent sentences. This one can be difficult to follow at first. You want to get down the question the provider is asking and be able to take that question and the patients’ answer and turn it into a sentence. You then have to take all of those sentences and form them into grammatically correct sentences and place them in an order that flows and makes sense. On top of that, if you are in a specialty or a visit where you aren’t solely focused on one problem (such as ER or urgent care), you have to learn to group certain things together to help form a picture of the issues they have.

How do I improve this? Well, this one you have to have some handle on listening and typing already. Then you need to start practicing with medical scenarios. There are some on youtube that you can listen to/watch. Most scribe companies have a website or certain scenarios you can watch/practice with that they’ve created. A lot of times scribe companies have books of scenarios. The problem with the books is you can’t listen and type it down. You can read it, but that’s kind of cheating. So have some friends or your family poorly act it out to help you out!

You want to take these conversations and start turning their questions/answers into those sentences.

⇒ You are taking layman terms and turning them into medical terminology/jargon. This is the nature of the field you are working in. Just like with law, medicine has its own language. In fact, most professions have their own type of language. It is also to help make things sound more professional and that you are more knowledgable in the subject.

How do I improve this? Well, you need to learn the terms. Flashcards help. Quizzing yourself helps. In fact, a lot of scribe training is based on of if you learned the terminology. I’m not joking. I’ve failed people before for not learning at least the required terms. It also helps when you are in your field because you are going to understand what is going on better if you know the terminology. Once you are more comfortable with the terminology you will likely start seeing yourself using it in your daily life without realizing it…

⇒ Flow and grammar of sentences/paragraphs. Part of this is learning what scenarios are associated with certain diseases/illnesses and what symptoms are grouped together by system. The other part of it is just practice. You want to be able to read it out loud and for it to flow like you are reading a story.

How do I improve this? Literally just practice. Reading out loud helps your ears catch mistakes and flow issues that your eyes gloss over or your brain corrects for you. Sometimes reading it either in a different format (like copy and pasting it into a word document, or reading it in a different format on the EMR you are in) helps catch some things as well. I stand by the muttering to yourself method though.

⇒ Timing. Oh man, this is another big issue. You need to be able to do all of the above and do it in a fairly short amount of time. Depending on the type of medicine/facility you are in will dictate how much time you have to write charts. Only seeing 5 patients a shift? Well congrats you have a shit ton of time. Although that’s not realistic. Seeing 22 patients in a shift? Now you are talking.

Some specialities you need to have your chart practically done when walking out of the room. Others you may have more time outside of the room to work on it. The biggest thing is knowing where to find your pockets of time throughout the visit to fix/tweak/and work on areas in your chart so that you have less to worry about working on when you leave that room.

⇒ Not understanding your shorthand. This was another interesting one. As a new scribble you will not be able to do all of the above right away. You will have to practice. There is no way you will be able to get a conversation down in full sentences at first.

As a former trainer I know you will have fragmented bullet points that you will have to spend time piecing back together. You will also not be able to type nearly as fast as you are still (hopefully) training your brain to improve the whole listening and typing thing. I suggest you make a shorthand that you can understand and that you won’t need to waste gobs of time on to try to decipher.

Practice

Now, your scribe company should have a stock of these for you to practice. When I worked for ScribeAmerica they had a separate login for employees that they could log on to their website and practice with any of the videos that they created. That way they could go back to the videos and try again. As a trainer, I would play these during classroom training and go over some of them that they come up with as a class to see how we could improve them. I would then usually give them an example of how I would write a HPI in that scenario.

Again, you may also be given a book of scenarios. If you have written scenarios given to you, you can practice putting the information together to learn to make cohesive sentences and improve flow of paragraphs. You can also work on switching layman terms into medical terminology. However, you are not learning how to listen and type or how to synthesize the information as well as it is written in front of you.

Lastly, a quick search on youtube can get you a fair amount of practice. They are usually older videos so the quality may not be as great, but you really only need the sound. You can also try to just type in “HPI mock” or “HPI audio” to get a few examples.

A lot of times these will be full scenarios. Just stop after the HPI or ROS at first. If the videos happen to have more information you can play the videos for longer once you start learning how to incorporate other areas of the chart!

Swedish Edmonds ED Scribes is a playlist on youtube with quite a few HPI practice scenarios from around the web. It does pull from multiple other accounts; mostly from the accounts ECCscribeprogram and ABC scribes. There are 18 videos in this playlist. This, combined with the access your scribe company will likely give you (on top of scenarios that you will be doing in classroom training!) should all be more than enough.

Remember, practice makes perfect. You will feel like you are drowning at first: that is really normal. I felt like I was drowning and not doing well for the first 3 months. The more you do it, the better you will get and the more comfortable you become.

Good luck!

As always, let me know what you liked, didn’t like, or what you would like to see next in the comments below!