Normal Review of Systems Documentation
A normal Review of Systems should be documented as negative for symptoms in each system.
Standard Phrasing Options
- “Review of Systems: Negative for chills, fatigue, fever, weakness.”
- “Review of Systems: Negative for HEENT symptoms, respiratory symptoms, cardiovascular symptoms, gastrointestinal symptoms, genitourinary symptoms, musculoskeletal symptoms, skin symptoms, neurologic symptoms, and psychiatric symptoms.”
- “Review of Systems: All other systems reviewed and are negative.”
System-by-System “Normal” Phrasing
- “Constitutional: Denies fever, chills, weight loss, fatigue.”
- “HEENT: Denies headache, vision changes, hearing loss, sore throat, nasal congestion.”
- “Respiratory: Denies cough, shortness of breath, wheezing.”
- “Cardiovascular: Denies chest pain, palpitations, edema.”
- “Gastrointestinal: Denies nausea, vomiting, abdominal pain, diarrhea, constipation.”
- “Genitourinary: Denies dysuria, hematuria, frequency, urgency.”
- “Musculoskeletal: Denies joint pain, muscle aches, back pain.”
- “Skin: Denies rash, itching.”
- “Neurologic: Denies dizziness, numbness, weakness.”
- “Psychiatric: Denies depression, anxiety.”
Shortest Acceptable “Normal” Ending
- “All other systems reviewed and are negative.”
Common Pitfall Avoidance
- Avoid listing only “ROS negative” without specifying that the reviewed systems were negative.
- Avoid including symptoms that conflict with the stated history of present illness or exam findings.