SYSTEMATIC PROBLEM ASSESSMENT & SUBJECTIVE DATA “Review of Systems” (ROS) J. Carley, MSN, MA, RN, CNE Fall, 2009

Example of Electronic Health Record (EHR) Review of Systems Screen

For each Symptom Onset Duration Severity Alleviating Factors Aggravating Factors

Helpful questions by system……………. Skin – Integumentary System Any 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 system Head and Neck Any headaches? Dizziness? Syncope? Head injuries? Loss or change in consciousness? Thyroid problems Swollen glands? Pain or stiffness of neck Any problems swallowing?

Helpful questions by system Eyes, Ears, Nose, Throat – EENT Visual 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 – EENT Frequent 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 – EENT Tooth abscesses or extractions? Swelling? Ulcers in mouth? Disturbance of taste? Last dental exam?

Helpful questions by system Respiratory System Last chest x-ray? Respiratory allergies? Smoker? Tobacco or others – how much? Dyspnea? When? Pain with breathing? Orthopnea?

Helpful questions by system Respiratory System Any cough? Sputum production? Hemoptysis? Wheezing? History of asthma, bronchitis,emphysema?

Helpful questions by system Respiratory System Labored respirations? Frequent colds? Exposure to environmental hazards? TB risk?

Helpful questions by system Cardiovascular Any chest pain? Any dizziness? Any syncope? Palpitations? Dyspnea?

Helpful questions by system Cardiovascular Hypertension? Familial risks? Smoker? Previous cardiac problems? Last EKG or cardiac tests? Edema? Where?

Helpful questions by system Cardiovascular Varicosities = varicose veins? Peripheral neuropathies? History of DVT? Swelling of feet, legs, hands Pressure, pain or heaviness in arms, jaw, or chest

Helpful questions by system Cardiovascular Leg pain or cramps? Bleeding problems? Anemias? SOB with exertion?

Helpful questions by system Breast & Chest Pain/tenderness? Swelling? Discharge? New assymmetry? Last mammogram? Lumps?

Helpful questions by system Neurological Loss of consciousness? Speech difficulty? Change in processing information? Swallowing difficulty? Confusion?

Helpful questions by system Neurological

Helpful questions by system Neurological Weakness? New Falls? Dropping items – weak grip? Change in balance, gait?

Helpful questions by system Neurological Blurred vision? Numbness or tingling of extremities? Changes in sensory perception?

Helpful questions by system Gastrointestinal Dyspepsia? Diarrhea? Constipation? Nausea or vomitting? Allergies/ food intolerances? Abdominal pain?

Helpful questions by system Gastrointestinal Bloating? Excess flatus? Belching? Change in color of stools? Change in consistency of stools? Pain with eating or defecating?

Helpful questions by system Genitourinary History of kidney or bladder disease? Urinary frequency? Burning? Nocturia? Changes in urine color? Clarity or odor of urine?

Helpful questions by system Genitourinary Pain? Excessive thirst? Swelling of legs, hands, eyelids? Dietary intake of calcium? Chills or fever? inability to urinate?

Helpful questions by system Genitourinary Hesitancy of urination? Incontinence?

Helpful questions by system Genitourinary – Reproductive Female 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 – Reproductive Fertility problems? Pain in breasts? Lumps? Pain or masses in testicles? Practices self-examination?

Helpful questions by system Musculoskeletal History of injuries or diseases? Back Pain? Limb or joint pain? Myalgias? Change in gait or balance? Neuropathies?

Helpful questions by system Musculoskeletal Weakness? Assymmetrical strength/reflexes? Pain? Swelling? Spasms?

Helpful questions by system Endocrine History 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 Endocrine Thinning or brittleness of hair? Increase in facial or body hair? Fatique? Insomnia? Nervousness? Palpitations?

Helpful questions by system Endocrine Growth 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 Psychosocial Any 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 Psychosocial Family/Marital problems Number of persons in household Income level/housing Health habits, exercise, gambling, etc..