Levels of Review of Systems (ROS)

1- Problem Pertinent

It is the lowest level of ROS. It requires only the evaluation of the system directly related to the problem(s) identified in the History of Present Illness (HPI)

2- Extended

This level of ROS requires 2-9 systems, always including the system related to the problem of the HPI.

3- Complete

This level of ROS requires 10 systems, always including the system related to the problem of the HPI. It is to note that "all other systems are reviewed and negative" can be used after the systems related to the problems identified in the HPI have been reviewed.

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed May 4, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Ramos, Marco. “Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems”. SMO Blog (blog). March 30, 2020. https://hive.blog/hive-122108/@secondmedicalop/clinical-documentation-improvement-series-17-evaluation-and-management-documentation-2-individual-systems-of-the-review-of

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 27. Evaluation and Management Documentation 12. Levels of Review of Systems”. SMO Blog (blog). May 7, 2020. https://hive.blog/hive-163521/@secondmedicalop/clinical-documentation-improvement-series-27-evaluation-and-management-documentation-12-levels-of-review-of-systems

Links to the Previous Posts in this Evaluation and Management Series

- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

- Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems

- Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History

- Clinical Documentation Improvement Series 19. Evaluation and Management Documentation 4. Organ Systems of the Physical Exam

- Clinical Documentation Improvement Series 20. Evaluation and Management Documentation 5. Problem Points of the Medical Decision Making

- Clinical Documentation Improvement Series 21. Evaluation and Management Documentation 6. Problem Points of the Medical Decision Making

- Clinical Documentation Improvement Series 22. Evaluation and Management Documentation 7. Risk Assessment: Minimal Risk

- Clinical Documentation Improvement Series 23. Evaluation and Management Documentation 8. Risk Assessment: Low Risk

- Clinical Documentation Improvement Series 24. Evaluation and Management Documentation 9. Risk Assessment: Moderate Risk

- Clinical Documentation Improvement Series 25. Evaluation and Management Documentation 10. Risk Assessment: High Risk

- Clinical Documentation Improvement Series 26. Evaluation and Management Documentation 11. Levels of History of Present Illness

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