Healthcare providers use different methods to examine their patients before making recommendations or diagnoses. A review of systems (ROS) is one of the methodologies used for examination.
A review of systems is primarily a set of questions a physician poses to the patient or client to collect information such as signs and symptoms about their medical condition.
Information obtained from these questions is then used as a basis for further tests and examinations.
Review of systems templates is used during the first encounter with a client, after which they are updated to accommodate changes in the patient’s medical progress. Therefore, it is essential to note that a ROS does not involve any hands-on tests and measures. Instead, the review of systems can be designed to suit a specific patient or client, demographic (age or sex), or clinical condition (e.g., depression). As a result, review of systems templates can be used to gather information about the problem and undetected underlying conditions of a patient during the screening period.
This article is a detailed guide on how review of systems are applied in healthcare and the essential components of a standard review of systems template.
Review of System Templates
Review of Systems
A review of systems, prepared by a physician, is an assessment tool that contains an array of questions arranged by body/organ systems to collect information about a patient’s clinical condition. The questions are designed to cover details about the probable medical condition and any underlying issues. The information collected through the review of systems template is used to determine additional assessments required and establish the objective of the subsequent examinations.
Note: There is no one-size-fits-all review of systems template. However, two qualities can characterize a good ROS; the ROS must aim to gather the history and current information of the patient’s complaint and target to discover symptoms of potential or undetected conditions. This way, the medical practitioner/physician can have a holistic understanding of the causes of concerns in all the patient’s body systems.
Systems of ROS
The review of systems template used will vary depending on the physician’s specialty and the patient’s complaint. However, an all-inclusive ROS should be based on the following 14 body systems:
- Constitutional symptoms (i.e., fatigue, fever, weight loss)
- Ears, nose, mouth, throat
How can it be applied?
A review of systems template is used to screen every patient. It usually marks the first interaction between the physician and the patient. If the ROS is already documented, the physician does not have to create a new ROS; they can review the existing review of systems and update with new questions to collect more information about symptoms the patient may have experienced in-between visits to the doctor.
A generic review of systems templates may not be as effective due to the diverse ways clinical conditions manifest in different patients. Therefore, targeted ROS – based on patient-specific characteristics – and specific clinical conditions are highly recommended. For example, the questions in the ROS can be targeted based on age and sex because clinical symptoms will often be consistent for a particular medical condition in each category of people.
A ROS helps lay the foundation of primary care and discover probable undiagnosed health conditions on the first encounter with the patient. While a ROS will rarely identify the specific condition, answers to the ROS questions point the physician in the right direction to take for diagnosis and treatment later on.
Additionally, when using ROS, the physician can collect information about the occupational and environmental exposures that are a risk to the patient’s health.
To a great extent, occupational and environmental exposures cause clinical symptoms that may easily be interpreted as diseases. Such information cannot be obtained through tests or examination hence depicting the importance of reviewing the systems template.
How to Use ROS?
Assessments involving a ROS template adopt a conversational format and tone. This allows the physician to ask far-reaching questions and help the patient answer truthfully. Therefore, it is up to the physician to determine the scope of the questions. Repetition is allowed for questions that apply to multiple body organs and illnesses.
The questions can be arranged in order of specificity, starting from generic to specific questions. Specialty is another factor that influences the type of questions in review of systems templates. For example, a neurologist and a therapist treating a headache will ask different questions to determine the cause of the same complaint.
The findings obtained from the ROS are not exhaustive. Positive responses call for follow-up questioning under the same category and tests to determine the root cause. Common medical conditions associated with the identified symptoms should be listed.
Other symptoms associated with the specific condition should be recorded as notes in the review of systems template, and they can be explored to identify the root cause. Symptoms can also be classified in the ROS. Common classifications include painful/painless, swollen/not swollen, acute/chronic, upper/lower, etc. Once documented, the ROS can be added to the patient’s medical records.
Levels of ROS
Depending on the physician’s objective, different levels of ROS are used in primary care. However, below are the three standard levels of ROS:
Problem pertinent ROS
A problem pertinent ROS is designed to suit the specific problem or complaint of the patient. The review of systems template questions are prepared to collect information about the positive and negative symptoms and responses occurring in one organ system.
An extended ROS assesses the body organ or system directly linked to the complaint or issue raised by the patient. In addition, the ROS can inquire about additional systems, typically two to nine systems. The review of systems template should record the positive and negative symptoms and responses of every system assessed.
An adequate review of systems (ROS) inquires about the system directly affected by the complaint and all other body systems or a minimum of ten body systems. The positive and negative symptoms and responses occurring in the primary system should be documented while only the negatives in other systems are recorded.
Note: An ROS is part of the first examination a physician performs on a patient. A standard subjective assessment entails the medical history section, a review of systems, and a tests and measures section.
Information in the History Section of ROS
Information on ROS may vary from one complaint, illness, or patient to another. As a result, it is advisable to create a standard review of systems template for reuse.
The following are the typical components that should be present in a review of the systems template:
The review of systems template ought to record the patient’s demographic information. Demographics are an efficient way of categorizing patients. Information that can be included in this section includes the patient’s name, mailing address or contact information, date of birth, biological sex, race/ethnicity, language, education level, date of visitation, advance directive preferences (inpatient or outpatient), etc.
Current condition/chief concerns
There should be a section in the ROS template to record the patient’s primary complaint. In addition, this section should record information such as type of complaint (headache, bleeding, coughing), the date when the problem was first observed or experienced, the probable cause of the condition (e.g., recent travel), history of the condition, or similar problems, already sort after interventions (such as OTC drugs) and things that repressor aggravate the condition.
The prior and current level of function
A record of the patient’s current and previous level of function should be given. This section should document the patient’s level of function and activities before the condition’s onset and how the two aspects have changed since. Information such as how the condition impedes their obligations at work, home, and community service should be recorded. If the patient has assumed more roles recently, this information should be documented.
Sometimes, the patient or their representative may have specific objectives they want to achieve regarding the patient’s healthcare. For example, for a therapy session, the goal could be to reduce the patient’s aggression level. Therefore, the review of systems template should have a section to record these objectives/goals.
The review of systems should also record any cultural and religious practices that may be affecting the patient’s health care. For example, this section can record who the patient was living with before the onset of the condition and details of their primary caregiver once they are discharged.
The template used in preparing the review of systems should document the patient’s employment status. Details captured in this section include the type of occupation, part-time or full-time, outdoor/indoor, specific physical tasks requirements, interaction with hazardous substances, etc.
The ROS can also outline the physical environment where the patient works and lives. Additionally, it can record any assistive devices such as wheelchairs, glasses, etc.
A review of systems is also referred to as systems inquiry. Physicians can extract pertinent details regarding different symptoms and responses of a medical condition exhibited in the different organs of the body system through the document. It combines information from the patient’s medical history and current illness to guide the physician in developing a suitable health care plan.
The application of the review of systems template will vary from one physician to another. Some physicians, such as general physicians, use it on every patient who visits their offices. Other physicians use it when the patient falls under a specific category of risk, for example, a therapist. Thirdly, some physicians use the ROS when a diagnosis has already been made to define better and understand the extent of the medical condition. Due to the wide range of applications of a ROS, using a reusable template to create a review of systems can be more convenient.