Review of Systems (ROS) Template & Checklist
Complete 14-point Review of Systems guide with questions for each body system, documentation levels, and E/M coding guidelines. Includes ready-to-use templates and examples.
What is a Review of Systems (ROS)?
A Review of Systems (ROS) is an inventory of body systems obtained through a series of questions to identify signs and/or symptoms the patient may be experiencing. It's a crucial component of the patient history that helps uncover conditions that may not be directly related to the chief complaint.
ROS vs. Physical Examination
Review of Systems
- •Patient-reported symptoms
- •Obtained through questions
- •Part of the history
- •Subjective information
Physical Examination
- •Clinician-observed findings
- •Inspection, palpation, auscultation
- •Part of the examination
- •Objective information
Three Levels of ROS Documentation
The extent of ROS documentation affects E/M coding and reimbursement.
Problem Pertinent
1 system
Inquires about the system directly related to the problem(s) identified in the HPI
Example:
For a patient with knee pain, review only the musculoskeletal system
Extended
2-9 systems
Inquires about the system related to the HPI plus a limited number of additional systems
Example:
For knee pain: musculoskeletal, neurological, and constitutional
Complete
10+ systems
Inquires about 10 or more organ systems, with at least one element documented for each
Example:
Comprehensive new patient evaluation covering all body systems
Complete 14-Point ROS Checklist
The CMS-recognized 14 body systems with sample questions and documentation examples.
Constitutional
System 1 of 14Questions to Ask:
- Fever or chills?
- Unintentional weight loss or gain?
- Fatigue or malaise?
- Night sweats?
- Loss of appetite?
Positive Finding Example:
Reports 10 lb weight loss over 2 months
Negative Documentation:
Denies fever, chills, night sweats, weight changes
Eyes
System 2 of 14Questions to Ask:
- Vision changes or blurring?
- Eye pain or redness?
- Double vision?
- Discharge or tearing?
- Light sensitivity?
Positive Finding Example:
Blurred vision when reading
Negative Documentation:
Denies vision changes, eye pain, discharge
Ears, Nose, Mouth, Throat (ENT)
System 3 of 14Questions to Ask:
- Hearing loss or tinnitus?
- Ear pain or discharge?
- Nasal congestion or discharge?
- Sore throat?
- Difficulty swallowing?
- Mouth sores?
Positive Finding Example:
Nasal congestion x5 days
Negative Documentation:
Denies hearing changes, ear pain, nasal symptoms, sore throat
Cardiovascular
System 4 of 14Questions to Ask:
- Chest pain or pressure?
- Palpitations?
- Shortness of breath with exertion?
- Leg swelling?
- Orthopnea or PND?
- Claudication?
Positive Finding Example:
Palpitations when climbing stairs
Negative Documentation:
Denies chest pain, palpitations, dyspnea, edema
Respiratory
System 5 of 14Questions to Ask:
- Cough (productive or dry)?
- Shortness of breath?
- Wheezing?
- Hemoptysis?
- Sleep apnea symptoms?
Positive Finding Example:
Productive cough with yellow sputum x3 days
Negative Documentation:
Denies cough, dyspnea, wheezing, hemoptysis
Gastrointestinal
System 6 of 14Questions to Ask:
- Nausea or vomiting?
- Abdominal pain?
- Diarrhea or constipation?
- Blood in stool?
- Heartburn or reflux?
- Changes in bowel habits?
Positive Finding Example:
Intermittent epigastric pain after meals
Negative Documentation:
Denies nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool
Genitourinary
System 7 of 14Questions to Ask:
- Dysuria (painful urination)?
- Frequency or urgency?
- Hematuria?
- Incontinence?
- Flank pain?
- Sexual dysfunction?
Positive Finding Example:
Urinary frequency x2 weeks
Negative Documentation:
Denies dysuria, frequency, urgency, hematuria, incontinence
Musculoskeletal
System 8 of 14Questions to Ask:
- Joint pain or swelling?
- Muscle pain or weakness?
- Back pain?
- Stiffness?
- Limited range of motion?
- History of fractures?
Positive Finding Example:
Right knee pain x2 weeks, worse with stairs
Negative Documentation:
Denies joint pain, muscle pain, back pain, stiffness
Integumentary (Skin)
System 9 of 14Questions to Ask:
- Rashes or skin changes?
- Itching?
- New or changing moles?
- Wounds that won't heal?
- Hair or nail changes?
Positive Finding Example:
Itchy rash on forearms x1 week
Negative Documentation:
Denies rashes, itching, skin lesions, hair or nail changes
Neurological
System 10 of 14Questions to Ask:
- Headaches?
- Dizziness or vertigo?
- Numbness or tingling?
- Weakness?
- Seizures?
- Memory problems?
- Tremors?
Positive Finding Example:
Intermittent headaches, frontal, 3x/week
Negative Documentation:
Denies headaches, dizziness, numbness, weakness, seizures
Psychiatric
System 11 of 14Questions to Ask:
- Depression or sadness?
- Anxiety?
- Sleep disturbances?
- Mood changes?
- Suicidal ideation?
- Hallucinations?
Positive Finding Example:
Difficulty sleeping x2 weeks
Negative Documentation:
Denies depression, anxiety, sleep disturbances, suicidal ideation
Endocrine
System 12 of 14Questions to Ask:
- Heat or cold intolerance?
- Excessive thirst or urination?
- Unexplained weight changes?
- Fatigue?
- Hair loss?
Positive Finding Example:
Increased thirst and urination x1 month
Negative Documentation:
Denies heat/cold intolerance, polydipsia, polyuria
Hematologic/Lymphatic
System 13 of 14Questions to Ask:
- Easy bruising or bleeding?
- Swollen lymph nodes?
- History of blood clots?
- Anemia symptoms?
Positive Finding Example:
Easy bruising noted on arms
Negative Documentation:
Denies easy bruising, bleeding, lymphadenopathy
Allergic/Immunologic
System 14 of 14Questions to Ask:
- Known allergies?
- Frequent infections?
- Autoimmune conditions?
- Seasonal allergies?
Positive Finding Example:
Seasonal allergies with rhinitis
Negative Documentation:
Denies allergies, frequent infections, autoimmune symptoms
Sample Complete ROS Documentation
Documentation Level: Complete (14 systems)
Visit Type: New Patient Evaluation
REVIEW OF SYSTEMS:
ROS Documentation Best Practices
Do
- • Start with open-ended questions before yes/no items
- • Tailor questions to the chief complaint
- • Document pertinent positives AND negatives
- • Use standardized language consistently
- • Note "all other systems negative" if reviewed
- • Include date when referencing prior ROS
Don't
- • Copy ROS from previous visits without review
- • Document systems you didn't actually ask about
- • Write "ROS unchanged" without a specific date
- • Mix ROS findings with physical exam findings
- • Use vague statements like "non-contributory"
- • Skip documentation of negative findings
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Frequently Asked Questions
What is a Review of Systems (ROS)?
A Review of Systems (ROS) is a systematic inventory of body systems obtained through a series of questions to identify signs and symptoms the patient may be experiencing. Unlike the physical exam (which documents clinician-observed findings), the ROS captures patient-reported symptoms. It helps uncover conditions that may not be directly related to the chief complaint.
How many body systems are in a complete ROS?
The Centers for Medicare and Medicaid Services (CMS) recognizes 14 body systems for ROS documentation: Constitutional, Eyes, ENT (Ears/Nose/Throat), Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary (Skin), Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, and Allergic/Immunologic. A complete ROS reviews 10 or more of these systems.
What are the three levels of ROS documentation?
The three levels are: Problem Pertinent (1 system related to the chief complaint), Extended (2-9 systems including the chief complaint system plus additional relevant systems), and Complete (10 or more systems). The level of ROS, combined with HPI and past medical/family/social history, determines the E/M documentation level for billing.
Can I use a previous ROS in my documentation?
Yes, a ROS from a prior encounter can be referenced if the physician reviews and updates the previous information. You must document that the ROS was reviewed, note any changes or state "ROS unchanged," and include the specific date and location of the earlier ROS. You cannot simply state "ROS unchanged from last visit" without the date.
What changed with the 2021 E/M guidelines regarding ROS?
The 2021 AMA/CMS E/M guideline revisions no longer require a complete ROS for every patient encounter. Providers now have more flexibility to tailor documentation based on medical decision-making or time rather than documentation elements. However, many providers still find ROS valuable for uncovering overlooked symptoms.
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