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Review of Systems (ROS) Medical Transcription Examples

REVIEW OF SYSTEMS: The patient denies any chills. Does note nausea, vomiting, diarrhea. Notes vague headache. Denies any dizziness, blurred vision, focal neurologic deficits, numbness, tingling or paresthesias to his extremities. Does note some increased fatigue and weakness. He denies any upper respiratory symptoms, neck pain or stiffness, chest congestion, cough, hemoptysis, hematemesis or hematochezia. He denies any chest pain, shortness of breath, wheezing, diaphoresis, palpitations. Denies any focal abdominal pain. Does note some crampy abdominal pain associated with episodes of emesis. Otherwise, denies any black, bloody or tarry stools. Denies any urinary frequency, urgency or dysuria, as well as any hematuria. Denies any evidence of rash. The remainder of review of systems is reviewed and negative.

REVIEW OF SYSTEMS: The patient notes fever and chills. Denies any nausea, vomiting or diarrhea. She denies any dizziness or blurred vision. Does note some vague headache. She denies any ear pain, red, itchy or watery eyes as well as any sinus pressure, congestion, or postnasal drainage. She denies any sore throat pain or difficulty swallowing. She denies neck pain, stiffness. She does note chest congestion, productive cough with sputum production as noted above. Denies any wheezing, diaphoresis, palpitations or abdominal pain as well as any back pain but does note some urinary frequency and urgency, but no dysuria. She denies any swelling to her extremities, numbness, tingling or paresthesias to the same. She denies any recent significant weight gain or weight loss. Remainder of review of systems was reviewed and negative.

REVIEW OF SYSTEMS: General: The patient states her appetite has been fine up until the last week. She denies any significant weight change. No fevers or chills. Hematologic: No history of bleeding disorders, blood clots, nor has she received a transfusion in the past. Endocrine: No history of thyroid disorders or diabetes. Respiratory: No history of pneumonia, tuberculosis or asthma. Cardiovascular: The patient denies any history of hypertension, palpitations, angina or cardiovascular disease. Gastrointestinal: No history of peptic ulcer disease, jaundice or hepatitis. Genitourinary: No history of any kidney problems or kidney stones. Neurologic: The patient does have a history of chronic low back pain. Orthopedic: No history of any long bone fracture. Psychiatric: The patient does have a history of depression and is on medication currently.

REVIEW OF SYSTEMS:  Denies fever, chills, sweats.  Eyes:  Denies dryness, irritation, visual loss.  ENT:  Denies earaches, hearing loss, no sinus problems.  Cardiovascular:  Positive for chest pain, palpitations and dyspnea.  Respiratory:  Positive for minor cough.  Gastrointestinal:  Denies heartburn, indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, constipation, diarrhea, bleeding.  Genitourinary:  Denies dysuria, urgency, frequency.  Musculoskeletal:  Denies muscle aches, arthritis or arthralgias.  Skin:  Denies rash or itching.  Neurologic:  Positive for headaches.  Denies focal weakness.  Psychiatric:  There is a history of depression.  She currently denies any depression.  Endocrine:  Denies thyroid problems, polyuria, polydipsia.  Hematologic:  Denies swollen lymph nodes or bleeding tendencies.

REVIEW OF SYSTEMS: Constitutional: No history of weight loss or weight gain recently. No fever, fatigue or chills. Eyes: The patient wears glasses. No history of glaucoma or cataract. Ear, Nose, and Throat: No vertigo. No frequent sore throat. No nosebleed. Genitourinary: No pain urinating. No burning. No nighttime urination. No hematuria. Respiratory: No shortness of breath. No wheezing. No persistent cough. Gastrointestinal: No abdominal pain. No upper or lower GI bleed. No diarrhea or constipation. Cardiovascular: No chest pain. No jaw pain. The patient complains of claudication of lower extremities after exercise. Hematological: Easy bruising. This is most likely due to use of aspirin and Plavix. Musculoskeletal: Complaining of stiffness, muscle pain, and back pain. Neurological: No seizure disorder. No memory loss. No loss of consciousness. Infectious disease: Positive for hepatitis C. Cardiovascular: Positive for high cholesterol and peripheral vascular disease. Endocrinology: Positive for diabetes and hypothyroidism.

REVIEW OF SYSTEMS: The patient notes transient fever. Denies any chills, nausea, vomiting, or diarrhea other than one episode of forced emesis. Denies any headache, dizziness, or blurred vision. Denies any focal neurologic deficits, numbness, tingling, or paresthesias to the extremities or muscle weakness. Denies any upper respiratory symptoms, neck pain, stiffness, chest congestion, cough, hemoptysis, or hematochezia. Denies any chest pain, shortness of breath, wheezing, diaphoresis, or palpitations. Notes generalized periumbilical abdominal distention with associated pain. Denies any black, bloody, or tarry stools as well as any fatty stools. Denies any back pain. Does note some dysuria and urinary urgency. Denies any urinary frequency. Denies any pelvic complaints and is not currently sexually active. She, otherwise, denies any evidence of rash or swelling to her extremities. The remainder of review of systems was reviewed and negative.

REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies. HEENT: Denies oral mucosal lesions. Claims she has had a sore throat and sore glands. She denies further symptoms. No difficulty swallowing. CARDIAC: Negative history of chest pain or palpitation. RESPIRATORY: Negative for shortness of breath, cough, and sputum production. GASTROINTESTINAL: Negative history of nausea, vomiting, or abdominal pain. GENITOURINARY: Negative history of hematuria or dysuria. GYNECOLOGIC: The patient denies possibility of pregnancy. She denies further issues. MUSCULOSKELETAL: Positive history of joint pain and absence of redness, swelling, or trauma.

REVIEW OF SYSTEMS: Constitutional: No fevers, night sweats, or weight loss. Head and Neck: No blurred vision or tinnitus. Pulmonary: No productive cough or hemoptysis. Gastrointestinal: No melena, bright red blood per rectum. Cardiovascular: See HPI. No PND, orthopnea, and no history of arrhythmias. Neurologic: No history of stroke or TIA. Rheumatologic: No history of joint swelling or pain.

REVIEW OF SYSTEMS: Chest tightness. Upper chest and shoulder pain in the right, radiation to the left, shortness of breath and diaphoresis. Worse with deep breathing and change in position. No hemoptysis, hematemesis, or hematochezia. No relevant change in bowel pattern. No leg swelling or leg weakness. No skin rash. No visual or hearing impairment. No fever, chills, shaking or weight loss reported.

REVIEW OF SYSTEMS: No CVA, TIA, or seizures. No chronic headaches. No asthma, TB, hemoptysis, or productive cough. There are no congenital heart abnormalities or rheumatic fever history. The patient is having palpitations. There is no nausea, vomiting, constipation, diarrhea, melena, peptic ulcer disease, or gastrointestinal problems. The patient is a non-insulin-dependent diabetic. He has no thyroid problems. There is no prostate problem. He complains of no dysuria or increased urinary frequency. There is no kidney or liver problem. There is no nausea, vomiting, constipation, melena, peptic ulcer disease, or gastrointestinal problems. The patient has depressive psychiatric problems. He has no bleeding problems, thrombosis, blood dyscrasias or anemia. He has no cancer history. He has never received any blood products in the past. He does have a history of chronic lower back pain and underwent previous lumbar surgery. He requires continued use of nonsteroidal anti-inflammatory medications for his pain. He has no history of gout. No changes in appetite or changes in weight.

REVIEW OF SYSTEMS: Denies any history of weight loss or gain. No fever, no fatigue in the recent past. No change in appetite. Eyes: The patient does not wear glasses. No history of double vision, glaucoma, or cataracts. Ears, Nose, and Throat: No history of vertigo, no frequent sore throat, no hoarseness, and no frequent nosebleed. Genitourinary: No pain urinating, no burning, no frequency, no hematuria, no history of sexually transmitted disease. Respiratory: No history of shortness of breath, no coughing, no wheezing in the recent past, no frequent infection. Gastrointestinal: No history of abdominal pain, no nausea, no vomiting, no upper or lower GI bleed, no diarrhea or constipation. Cardiovascular: No history of chest pain, no jaw pain, no arm pain, no calf pain, no palpitations or swelling of the extremities. Hematological: No easy bruising, hypercoagulable state, no enlarged glands. Musculoskeletal: No stiffness, no muscle pain, no back pain. Neurological: No seizure disorder, no memory loss, no loss of consciousness, no headaches. Skin: No rashes, no sores, itching or burning.

REVIEW OF SYSTEMS: Constitutional: No real or clear history of weight gain or weight loss over the past few years. Positive for low-grade fever in the recent past. HEENT: Multiple problems with teeth, with tooth decay. The patient wears glasses for reading. No history of frequent headaches or epistaxis. Endocrinology: No history of hypothyroidism or hyperthyroidism. No history of diabetes mellitus. Lungs: History of COPD with recent productive cough. Long history of tobacco abuse but she quit some months ago. No wheezing or rales. No hemoptysis. No positive history of tuberculosis. Cardiac: No history of hypertension or hyperlipidemia. No history of murmur or heart disease. Gastrointestinal: Long history of upper and lower GI symptoms with history of pancreatitis, gastritis, duodenitis, peptic ulcer disease, but no clear origin of this chronic and persistent nausea and vomiting as well as intermittent diarrhea. No recent upper or lower GI bleed. Musculoskeletal: History of fibromyalgia with right knee pain, right upper extremity pain, and generalized muscle pain for which she has been taking methadone for a long time. There is intermittent swelling in the right upper extremity, probably secondary to muscle ache. Genitourinary: No dysuria or hematuria. No history of kidney stone. Neurologic: No seizure disorder. No CVA or neuro deficit. Psychiatry: Some history of depression. Hematological: No history of hypercoagulable state. No bleeding disorders.

Review of Systems MT Examples # 2   Review of Systems Example # 3 

ROS Examples # 3


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