Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Review of Systems Template Sample Words and Phrases

CONSTITUTIONAL: No weight loss, fever, weakness or fatigue.
HEENT:  No vision loss or blurred vision. The patient does wear glasses. No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure, chest discomfort, palpitations or edema.
RESPIRATORY: No shortness of breath or cough.
GASTROINTESTINAL: Has had nausea, vomiting, diarrhea as described above. Abdominal cramping as described above. No blood.
GENITOURINARY: No dysuria, frequency or hematuria.
NEUROLOGIC: Complains of headache as described above. No dizziness, no syncope, no paralysis and no ataxia. Denies loss of control of bowels or bladder.
MUSCULOSKELETAL: No joint pain or stiffness.
HEMATOLOGIC: No history of anemia or bleeding.
LYMPHATICS: No enlarged nodes or splenectomy.
SKIN: No rash or itching.

REVIEW OF SYSTEMS:  CONSTITUTIONAL: No weight loss, fever, weakness or fatigue. HEENT:  No visual loss, blurred vision, double vision or yellow sclerae. No hearing loss, sneezing, congestion, runny nose or sore throat. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: Shortness of breath. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No dysuria, frequency or hematuria. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES:  No history of asthma, hives, eczema or rhinitis. SKIN: No rash or itching.

REVIEW OF SYSTEMS:  The patient denies headache, dizziness or loss of consciousness.  Denies changes in vision or loss of vision.  Denies ringing or buzzing in the ear.  Denies nasal congestion or epistaxis.  Denies sore throat, dysphagia or odynophagia.  Denies cough or hemoptysis.  Denies chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea.  Denies abdominal pain, diarrhea or constipation.  Her right foot is not painful at this time.  Her surgical site is slightly sore.  She denies seizures.  Denies melena or bright red blood per rectum.

REVIEW OF SYSTEMS:  No fever, chills or night sweats. No headaches, visual disturbances, mouth pain, bleeding gums, tooth pain, tongue swelling or dysphagia. The patient is experiencing difficulty masticating certain food textures. Neck muscles are sore but without significant stiffness. Skin has no gross discolorations, rashes or itching. No pain, shortness of breath, palpitations, PND, orthopnea or edema. No nausea, vomiting or diarrhea. No bleeding or hematochezia. No dysuria, pyuria or hematuria. No flank pain. No seizure, syncope, headache, diplopia, dysarthria or worsening paresthesias.

REVIEW OF SYSTEMS: CONSTITUTIONAL:  The patient has gained some weight.  Denies any fever, chills or sweats. HEENT:  No visual change, no eye pain or diplopia.  No rhinorrhea, ear pain or sore throat.  Has some difficulty swallowing. CARDIOVASCULAR:  Denies chest pain or palpitation.  No history of heart attack. PULMONARY:  Has mild shortness of breath, no pneumonia, no TB. GASTROINTESTINAL:  Denies diarrhea or blood in the stool.  No stomach ache. GENITOURINARY:  Has no dysuria, flank pain, discharge or rash. NEUROLOGY:  Had multiple falls over the last couple of months, but no seizure or syncope. ENDOCRINE:  Has history of diabetes. MUSCULOSKELETAL:  Has arthritis. PSYCHIATRIC:  Looks depressed. HEMATOLOGY:  No history of anemia.

REVIEW OF SYSTEMS:  No CHF or palpitations.  No history of heart attack.  Normal nuclear stress test.  No complaints of asthma, emphysema or cough.  No shortness of breath.  Mild dyspnea on exertion, relieved by rest.  No history of ulcer, abdominal pain, nausea or vomiting.  No melena, hematochezia, hematemesis, ulcers, colitis, liver disease, pancreas problems or gallbladder problems.  No complaints of dysuria, hematuria or flank pain.  No claudication, peripheral edema or phlebitis issues.  Minor arthritic complaints at the hips and knees.  Hearing, speech and vision grossly normal.  No history of thyroid disease or carotid blockage.  No history of stroke.  Memory has been good.  No Alzheimer's history.

REVIEW OF SYSTEMS:  No TIA, blackout spells or seizure disorder.  No history of amaurosis.  Has had some lightheadedness.  No recent history of fever, chills or diaphoresis.  No headache but he has had a slight tremor.  No history of sputum production.  No hemoptysis.  No shortness of breath.  No orthopnea.  No dyspnea.  No recent chest pain or chest pressure.  No claudication.  No history of heart murmur.  Has never had veins stripped out of the legs.  Has got no nausea, vomiting or diarrhea.  No change in bowel or bladder habits.  No melena.  No pain with urination.  No blood in his urine and no hesitancy.  Does not have any skin bruisability or bleeding tendency.  Has had no history of neurologic or psychiatric disorders and had no history of endocrine disorders and no history of skin rash.

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