10.review of systems
TRANSCRIPT
SYSTEMATIC PROBLEM ASSESSMENT&
SUBJECTIVE DATA
“Review of Systems”(ROS)
J. Carley, MSN, MA, RN, CNEFall, 2009
Example of Electronic Health Record (EHR)
Review of Systems Screen
For each Symptom
OnsetDurationSeverityAlleviating FactorsAggravating Factors
Helpful questions by system…………….
Skin – Integumentary SystemAny changes in color?Any pain or enlargement?Any itching or rashes?History of scarring or diseases?Sores that will not heal?Allergies to environmental allergens or food?Any new medications?
Helpful questions by systemHead and NeckAny headaches?Dizziness?Syncope?Head injuries?Loss or change in consciousness?Thyroid problemsSwollen glands?Pain or stiffness of neckAny problems swallowing?
Helpful questions by system
Eyes, Ears, Nose, Throat – EENTVisual acuity problems? Changes?Last eye exam?Pain ? Where?Hearing loss?Discharge or drainage?Vertigo?Tinnitus?Sense of Smell?
Helpful questions by system
Eyes, Ears, Nose, Throat – EENTFrequent colds?Epistaxis?Postnasal drainage?Allergies?Recurrence of symptoms?Change in voice?Sore throat?Bleeding or Swelling of the gums?
Helpful questions by system
Eyes, Ears, Nose, Throat – EENTTooth abscesses or extractions?Swelling?Ulcers in mouth?Disturbance of taste?Last dental exam?
Helpful questions by system
Respiratory SystemLast chest x-ray?Respiratory allergies?Smoker? Tobacco or others – how much?Dyspnea? When?Pain with breathing?Orthopnea?
Helpful questions by system
Respiratory SystemAny cough?Sputum production?Hemoptysis?Wheezing?History of asthma, bronchitis,emphysema?
Helpful questions by system
Respiratory SystemLabored respirations?Frequent colds?Exposure to environmental hazards?TB risk?
Helpful questions by system
CardiovascularAny chest pain?Any dizziness?Any syncope?Palpitations?Dyspnea?
Helpful questions by system
CardiovascularHypertension?Familial risks?Smoker?Previous cardiac problems?Last EKG or cardiac tests?Edema? Where?
Helpful questions by system
CardiovascularVaricosities = varicose veins?Peripheral neuropathies?History of DVT?Swelling of feet, legs, handsPressure, pain or heaviness in arms, jaw, or chest
Helpful questions by system
CardiovascularLeg pain or cramps?Bleeding problems?Anemias?SOB with exertion?
Helpful questions by system
Breast & ChestPain/tenderness?Swelling?Discharge?New assymmetry?Last mammogram?Lumps?
Helpful questions by system
NeurologicalLoss of consciousness?Speech difficulty?Change in processing information?Swallowing difficulty?Confusion?
Helpful questions by system
Neurological
Helpful questions by system
NeurologicalWeakness?New Falls?Dropping items – weak grip?Change in balance, gait?
Helpful questions by system
NeurologicalBlurred vision?Numbness or tingling of extremities?Changes in sensory perception?
Helpful questions by system
GastrointestinalDyspepsia?Diarrhea?Constipation?Nausea or vomitting?Allergies/ food intolerances?Abdominal pain?
Helpful questions by system
GastrointestinalBloating?Excess flatus?Belching?Change in color of stools?Change in consistency of stools?Pain with eating or defecating?
Helpful questions by system
GenitourinaryHistory of kidney or bladder disease?Urinary frequency?Burning?Nocturia?Changes in urine color?Clarity or odor of urine?
Helpful questions by system
GenitourinaryPain?Excessive thirst?Swelling of legs, hands, eyelids?Dietary intake of calcium?Chills or fever?inability to urinate?
Helpful questions by system
GenitourinaryHesitancy of urination?Incontinence?
Helpful questions by system
Genitourinary – ReproductiveFemale history of pregnancy G: P: A:Onset of menses?Last menstrual cycle?Onset of menopause?Unusual bleeding?Impotence?
Helpful questions by system
Genitourinary – Reproductive Prostate problems?Age when sexually active?Sexual partners? Any new ones?Pain with sex?Change in libido?
Helpful questions by system
Genitourinary – ReproductiveFertility problems?Pain in breasts? Lumps?Pain or masses in testicles?Practices self-examination?
Helpful questions by system
MusculoskeletalHistory of injuries or diseases?Back Pain?Limb or joint pain?Myalgias?Change in gait or balance?Neuropathies?
Helpful questions by system
MusculoskeletalWeakness?Assymmetrical strength/reflexes?Pain?Swelling?Spasms?
Helpful questions by system
EndocrineHistory of endocrine disorders?Excessive thirst, hunger, frequent urination?Cuts or sores that are slow to heal?Unexplained weight gain or loss?Changes in skin texture or color?Exopthalmos?
Helpful questions by system
EndocrineThinning or brittleness of hair?Increase in facial or body hair?Fatique?Insomnia?Nervousness?Palpitations?
Helpful questions by system
EndocrineGrowth normal for age?Changes in hair patterns?Change in menstrual patterns?
Regular or irregular?Weight loss or gain?Cold or heat intolerances?
Helpful questions by system
PsychosocialAny history of psychiatric problems?Marital status?Use of illicit drugs?Smoker?Alcohol?Ethnic/cultural background?
Helpful questions by system
Psychosocial?Occupation? If retired….from what profession?Educational level?Religious preference?Usual language?Health insurance?Difficulty sleeping, anxiety, depression, or fatigue?
Helpful questions by system
PsychosocialFamily/Marital problemsNumber of persons in householdIncome level/housingHealth habits, exercise, gambling, etc..