Review of Systems Medical Transcription Samples

GASTROINTESTINAL: The patient denies any nausea, vomiting, abdominal pain, history of ulcers, hemorrhoids, blood in the stool, black tarry stool or melena.
GENITOURINARY: The patient denies any polyuria, hematuria, dysuria, frequency or urinary tract infection.
CARDIOVASCULAR: The patient denies any chest pain, substernal or radiating, previous cardiac disease or hypertension.
LUNGS: The patient denies any tuberculosis, pneumonia, asthma, pleurisy, bronchitis or sinusitis.
NEUROLOGICAL: The patient denies any seizures, convulsions, unconsciousness, speech difficulty or ataxia.

REVIEW OF SYSTEMS:  The patient denies any nausea, vomiting, headache, diarrhea, constipation, fits, pains, seizures, psychiatric disorders or bowel and bowel dysfunction.

REVIEW OF SYSTEMS:  No stroke, seizure, visual disturbances, glaucoma, cataract, hearing imbalance, nasal or sinus disease. No significant acid reflux or heartburn. The patient may have had ulcers in the remote past. No hepatitis or gallbladder disease. Denies chronic lung disease, asthma, bronchitis, pneumonia or tuberculosis. Denied heart disease or rheumatic fever. Had cardiac clearance prior to current surgery. Denies any colon disorders. Currently, the acute problems are nausea, vomiting, abscess and bowel movements with flatus. No chronic GU complaints or problems. No other musculoskeletal complaints, diabetes, thyroid disease or dyslipidemia. No skin disorder such as eczema or psoriasis.

GENERAL:  The patient is not in acute distress.
CARDIOVASCULAR:  Had some chest tightness and shortness of breath but not now.
RESPIRATORY:  Had shortness of breath, mainly due to congestive heart failure and that improved after getting diuretics.
GASTROINTESTINAL:  No abdominal pain and no hematemesis or melena.
ENDOCRINE:  Has diabetes.
GENITOURINARY:  No complaints.
HEMATOPOIETIC:  No anemia or coagulopathy.
RENAL:  The patient had prior history of renal insufficiency.
CENTRAL NERVOUS SYSTEM:  No problems at the present time, though in the past stroke was mentioned.

REVIEW OF SYSTEMS:  Denies headache, diplopia, blurred vision, loss of vision, hearing loss. Denies any sinusitis or sore throat. Denies chest pain, pressure, palpitations or orthopnea. No pedal edema. Denies shortness of breath, cough, sputum production, hemoptysis, pleuritic pain or wheezing. Complains of nausea. Denies vomiting, constipation, diarrhea, hematochezia or hematemesis. Denies dysuria, hematuria, nocturia, frequency or polyuria. Neurologic: Complains of syncopal episode. Denies seizures, vertigo, paresthesia, weakness or tremor.

HEENT:  No acute interval change.
CARDIOVASCULAR:  No chest pain, palpitations.
PULMONARY:  Negative for cough, shortness of breath.
GASTROINTESTINAL:  Chronic constipation.
MUSCULOSKELETAL/ORTHOPEDIC:  No pain at this time at rest. The patient states that discomfort does surge to 5 or 6 over 10 with activity and weightbearing.
NEUROLOGIC:  Admits to some numbness and tingling in the left lower extremity distally.

REVIEW OF SYSTEMS:  Not noted any headache, nasal congestion, sore throat or other head symptoms. Does not feel short of breath, nor does she have any difficulty in swallowing or digestion. Has had no pain in the chest. No pains in the abdomen. No nausea, vomiting, diarrhea or constipation. Has not noted any pain when urinating, which she does continue to do to a small degree. There has been no blood in the stool or black tarry bowel movements. The patient reports no pain in any of the extremities, no joint stiffness or swelling and no weakness or numbness in any of the extremities. The patient states that she has not noticed any rashes on the skin or any sore spots.

REVIEW OF SYSTEMS:  Negative for weight loss or weight gain. A bit of fatigue and some dyspnea on exertion. Denies any difficulty with her vision or hearing. No difficulty swallowing, nausea, vomiting, diarrhea, blood in her stool or blood in her urine. Has no difficulty with back pain, knee pain or joint pain. No history of arthritis. Denies any history of diabetes or thyroid disease. No history of calcium or other endocrine disorders. Denies history of any loss of consciousness, distress or seizures. Denies any skin disorder. Denies any history of any psychiatric illness. Has not had any skin lesions or difficulty with hepatitis. Has not had any urinary tract infections. Has not had an MI. No other difficulty with chest pain.

REVIEW OF SYSTEMS:  The patient denies any fever, chills or night sweats. No headaches, lightheadedness or dizziness. No recent trauma or loss of consciousness. No nausea, vomiting, diarrhea or constipation. No hemoptysis, hematemesis, hematuria or bright red blood per rectum. No chest pain or chest tightness. No palpitations, paroxysmal nocturnal dyspnea or orthopnea. Does describe shortness of breath and dyspnea on exertion. Describes a cough which is productive of whitish-yellowish sputum. No previous history of pulmonary embolism or deep venous thrombosis. No heat or cold intolerance. No history of thyroid disease. Denies any abdominal pain. No joint redness, tenderness or inflammation. The patient does describe secondhand cigarettes smoker’s exposure past weekend. Does complain of discolored urine but denies any dysuria or burning sensation with urination. Remainder of review of systems is negative.

ROS Examples    ROS Examples 1

REVIEW OF SYSTEMS:  Significant for some forgetfulness and a prior CVA. Has arthritis of multiple joints. Has had chills but denied any fevers. Denied any problems with excessive bleeding but does have easy bruising, especially on lower extremities. Denied any symptoms of chest pain or palpitations. Has mild dyspnea on exertion. Denied any cough. Denied any dysuria or hematuria but has had some mild decreased urine output and dark orange-colored urine. Has depression and anxiety.

REVIEW OF SYSTEMS:  The patient denies any recent fevers, chills, nausea or vomiting. Denies any weight changes or appetite changes. Denies any headaches, blurry vision, diplopia, slurred speech, cough or change in voice. Denies any unusual chest pain, palpitations, lightheadedness, shortness of breath or dyspnea on exertion. Denies any unusual abdominal pain, constipation or diarrhea. Denies any lower extremity edema, PND or orthopnea. Denies any unusual paresthesias.

ROS Examples 2

CONSTITUTIONAL:  Negative for any fevers, chills, night sweats, tiredness, fatigue, malaise, anorexia or weight loss.
CARDIOVASCULAR:  Negative for chest pain, palpitations, dizziness, orthopnea or lower extremity edema.
RESPIRATORY:  Negative for shortness of breath, cough, wheezing, sputum.
GENITOURINARY:  Negative for frequency, nocturia, dysuria, hematuria.
GYNECOLOGIC:  Negative for abnormal bleeding.
HEMATOLOGIC:  Negative for any abnormal bleeding or bruising.
MUSCULOSKELETAL:  Negative for joint swelling, stiffness or pain.
SKIN:  Negative for rashes, eruptions, lesions or dryness.
NEUROLOGIC:  Negative for any focal neurologic complaints.
PSYCHIATRIC:  Negative for anxiety, panic, depression.

ROS Examples 3

REVIEW OF SYSTEMS:  Negative for any weight loss or weight gain. Has not had difficulty with vision. Previously has had glaucoma. Does wear glasses. Has no difficulty swallowing. Severely hard of hearing even with hearing aids. Has had increased runny nose with sinus pain but no sore throat prior to this time. Denies any chest pain or palpitations. Never had myocardial infarction. Hypertensive. Does have a questionable of history of congestive heart failure. Does have atrial fibrillation and is on Coumadin. Does not usually wheeze. Does not usually have a cough. Denies any history of nausea or vomiting, hematochezia or hematuria. No hernias. Has not had any gastroesophageal reflux syndrome. Denies any difficulty with urinating. No burning pain, constipation or diarrhea. Has not had any apparent problems after cystocele and rectocele repair. Denies any rashes or bruising or hives. Tells me extremities are usually cold and occasionally has lower extremity edema. Denies any recent falls. No loss of consciousness, seizures or paresthesias.

ROS Example 4

REVIEW OF SYSTEMS:  There are no visual disturbances. No sinus congestion or epistaxis. No shortness of breath, cough, sputum production, breathlessness, hemoptysis, pleurodynia, exertional chest pain, orthopnea or PND. No anorexia, hematochezia, melena or hematemesis. No dysphagia or odynophagia. No abdominal complaints, nausea, vomiting, diarrhea or constipation. No polydipsia or polyphagia. No dysuria, hematuria or polyuria. No weight loss. No bleeding. No recent infections. No fevers, chills, night sweats or new adenopathy. No bone pain, falls or fractures. No lateralizing or localizing neurologic deficits. No altered mental status. No headaches, except for multiple aches and pains and joint pain.

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