Review of systems documentation


CONST: Negative for fever, body aches and chills.

HENT: Negative for neck pain/stiffness, headache, congestion, sore throat, swelling.

EYES: Negative for discharge/pain or vision changes.

RESP: Negative for cough/hemoptysis and shortness of breath.

CV: Negative chest pain, difficulty breathing, palpitations.

ABD: Negative pain, nausea, vomiting.

GU: Negative increase frequency, dysuria, blood in urine or stool.

MUSC: Negative for muscle aches, edema.

SKIN: Negative rash, lesions/sores.

NEURO: Negative headache, dizziness, weakness.

[brackets added to be uploaded into dragon for quick editing. This ROS meets CMS standards for level 5 documentation]