{"id":183124,"date":"2026-08-17T12:37:58","date_gmt":"2026-08-17T12:37:58","guid":{"rendered":"https:\/\/pabau.com\/?p=183124"},"modified":"2026-08-17T13:28:50","modified_gmt":"2026-08-17T13:28:50","slug":"normal-review-of-systems","status":"publish","type":"post","link":"https:\/\/pabau.com\/es\/templates\/normal-review-of-systems\/","title":{"rendered":"Normal review of systems: Free 14-system template"},"content":{"rendered":"\n<script type=\"application\/ld+json\">{\"@context\":\"https:\/\/schema.org\",\"@type\":\"MedicalWebPage\",\"headline\":\"Normal review of systems: copy-paste wording for all 14 systems\",\"description\":\"A normal review of systems documents 14 organ systems as negative findings. Copy-paste wording, specialty variants, and the 2021 E\/M coding rules.\",\"url\":\"https:\/\/pabau.com\/templates\/normal-review-of-systems\/\",\"audience\":{\"@type\":\"MedicalAudience\",\"audienceType\":\"Clinician\"},\"reviewedBy\":{\"@type\":\"Person\",\"name\":\"Dr Vanja Kitanova\",\"jobTitle\":\"Medical Reviewer\",\"affiliation\":{\"@type\":\"Organization\",\"name\":\"Pabau\"},\"knowsAbout\":[\"Medical Documentation\",\"Clinical Assessment\",\"Healthcare Compliance\",\"Clinical Safety\"],\"sameAs\":\"https:\/\/pabau.com\/blog\/author\/vanja\/\"},\"mainEntity\":{\"@type\":\"DigitalDocument\",\"name\":\"Normal review of systems\",\"description\":\"A medical assessment form covering all 14 organ systems, with ready-to-use negative findings wording and primary care, psychiatry, and cardiology variants.\",\"encodingFormat\":\"application\/pdf\",\"url\":\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/templates\/normal-review-of-systems\/normal-review-of-systems.pdf\",\"inLanguage\":\"en\",\"isAccessibleForFree\":true,\"offers\":{\"@type\":\"Offer\",\"price\":\"0\",\"priceCurrency\":\"GBP\",\"availability\":\"https:\/\/schema.org\/InStock\"},\"hasDigitalDocumentPermission\":{\"@type\":\"DigitalDocumentPermission\",\"permissionType\":\"https:\/\/schema.org\/ReadPermission\"},\"author\":{\"@type\":\"Organization\",\"name\":\"Pabau\",\"url\":\"https:\/\/www.pabau.com\"},\"datePublished\":\"2026-08-17\"},\"datePublished\":\"2026-08-17\",\"dateModified\":\"2026-08-17\"}<\/script>\n\n\n        <div id=\"key_takeaways\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/12\/Key-Takeaways-Icon.svg\" alt=\"Key takeaways\" height=\"42\" width=\"42\">\n                                <h3>Key takeaways<\/h3>\n            <\/div>\n            <div class=\"list\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>A normal review of systems records what the patient denies across 14 organ systems, in wording an auditor can follow.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>CMS counts one problem-pertinent system as expanded problem-focused, 2 to 9 as detailed, and 10 or more as complete.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Since 2021, office visit codes 99202 to 99215 are selected by medical decision-making or total time, not by history.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>CMS permits the phrase \u00aball other systems reviewed and normal\u00bb once the pertinent positives and negatives are documented individually.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#3D3D46\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p>Pabau captures the review of systems as structured intake data, so the wording reaches the note without anyone retyping it.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<div style=\"background: linear-gradient(135deg, #E2F2FD 0%, #DFE3FD 100%); border-radius: 16px; padding: 40px; margin: 32px 0;\">\n<h2 style=\"margin: 0 0 12px 0; font-size: 22px; color: #121d36;\">Download your free normal review of systems template<\/h2>\n<p style=\"margin: 0 0 20px 0; color: #444; font-size: 15px;\">The template lists all 14 organ systems with ready-to-use negative findings wording, plus primary care, psychiatry, and cardiology variants. Print it for the exam room, or paste the wording straight into your EHR.<\/p>\n<a style=\"display: inline-block; background: #037CD2; color: #fff; padding: 14px 28px; border-radius: 8px; text-decoration: none; font-weight: 600; font-size: 15px;\" href=\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/templates\/normal-review-of-systems\/normal-review-of-systems.pdf\" target=\"_blank\" rel=\"noopener\">Download template<\/a>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Most reviews of systems come back clean. The patient denies everything you ask, and you type the same 60 words you typed for the last six patients.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">That repetition is where documentation quality slips. Wording drifts between visits, a system quietly gets skipped, and a chart that felt thorough in the room reads thin under review.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A standing template solves most of that. Below is the wording for all 14 systems, three specialty variants, and the coding rules that changed underneath them in 2021.<\/p>\n\n\n\n<h2 id=\"h-a-normal-ros-records-what-the-patient-denies\" class=\"wp-block-heading\">A normal ROS records what the patient denies<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>normal review of systems<\/strong> is a written record of symptoms the patient does not have. You ask about each organ system, the patient reports nothing abnormal, and you document that as a negative finding.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Those negatives do two jobs. First, they show you asked, which is what <a href=\"https:\/\/www.cms.gov\/medicare\/payment\/fee-schedules\/physician\/evaluation-management-visits\" target=\"_blank\" rel=\"nofollow noopener\">CMS documentation rules<\/a> turn on. Second, they set a clinical baseline.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The baseline matters more than clinicians expect. When a patient returns in March reporting chest pain, a clean cardiovascular ROS from January says the symptom is new. That one detail changes both your differential and your coding.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/downloadable_template_article\/normal-review-of-systems\/digital-forms.webp\" alt=\"Pabau digital intake form builder\"\/><figcaption class=\"wp-element-caption\"><em>Pabau&#8217;s digital intake forms collect the review of systems before the visit, so the negatives are already in the chart.<\/em><\/figcaption><\/figure>\n\n\n\n<div style=\"height:35px;width:800px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 id=\"h-the-14-systems-a-complete-review-has-to-touch\" class=\"wp-block-heading\">The 14 systems a complete review has to touch<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The CMS 1995 and 1997 documentation guidelines name 14 organ systems. Each one covers a distinct set of symptoms:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Constitutional:<\/strong> General appearance, fever, weight loss or gain, chills, fatigue, malaise<\/li>\n\n\n\n<li><strong>Eyes:<\/strong> Vision changes, eye pain, double vision, discharge<\/li>\n\n\n\n<li><strong>ENT (ear, nose, throat):<\/strong> Hearing loss, tinnitus, vertigo, sore throat, rhinitis, nosebleeds<\/li>\n\n\n\n<li><strong>Cardiovascular:<\/strong> Chest pain, palpitations, orthopnea, dyspnea on exertion, edema<\/li>\n\n\n\n<li><strong>Respiratory:<\/strong> Cough, dyspnea, hemoptysis, wheezing, asthma<\/li>\n\n\n\n<li><strong>Gastrointestinal:<\/strong> Nausea, vomiting, constipation, diarrhea, abdominal pain, rectal bleeding<\/li>\n\n\n\n<li><strong>Genitourinary:<\/strong> Dysuria, frequency, urgency, hematuria, incontinence<\/li>\n\n\n\n<li><strong>Musculoskeletal:<\/strong> Joint pain, muscle aches, back pain, stiffness, weakness<\/li>\n\n\n\n<li><strong>Skin:<\/strong> Rash, itching, lesions, hair loss, nail changes<\/li>\n\n\n\n<li><strong>Neurological:<\/strong> Headache, dizziness, syncope, tremor, seizures, weakness, numbness<\/li>\n\n\n\n<li><strong>Psychiatric:<\/strong> Mood changes, anxiety, depression, suicidal ideation, psychosis<\/li>\n\n\n\n<li><strong>Endocrine:<\/strong> Heat or cold intolerance, excessive urination, excessive thirst, weight changes<\/li>\n\n\n\n<li><strong>Hematologic and lymphatic:<\/strong> Easy bruising, bleeding, swollen lymph nodes<\/li>\n\n\n\n<li><strong>Allergic and immunologic:<\/strong> Allergies, anaphylaxis, recurrent infections, HIV status<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Count the systems as you go. Ten or more gives you a complete review. Two to nine is detailed. A single problem-pertinent system counts as expanded problem-focused, and a problem-focused history needs no ROS at all.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Shorter formats exist as well. A <a href=\"https:\/\/pabau.com\/templates\/12-point-review-of-systems\/\">12-point review of systems<\/a> still clears the 10-system threshold with less typing, which suits high-volume schedules.<\/p>\n\n\n\n<h2 id=\"h-copy-paste-wording-for-a-full-normal-review-of-systems\" class=\"wp-block-heading\">Copy-paste wording for a full normal review of systems<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Here is the wording for a complete normal ROS. Use it as written, or adjust the phrasing to match how your practice charts. The language stays neutral and does not lead the patient.<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Body system<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Normal documentation wording<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Constitutional<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Patient denies fever, chills, weight loss, or fatigue.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Eyes<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No vision changes, eye pain, double vision, or discharge.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">ENT<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No hearing loss, tinnitus, sore throat, or nosebleeds.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Cardiovascular<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No chest pain, palpitations, orthopnea, or exertional dyspnea. No leg swelling.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Respiratory<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Patient denies cough, shortness of breath, or coughing blood.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Gastrointestinal<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No nausea, vomiting, abdominal pain, constipation, or diarrhea.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Genitourinary<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No painful urination, frequency, urgency, or blood in the urine.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Musculoskeletal<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No joint pain, back pain, or muscle weakness.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Skin<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Patient denies rash, lesions, or changes in the skin.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Neurological<\/td>\n<td style=\"padding:12px 16px;color:#374151\">Patient denies headache, dizziness, fainting, tremor, or weakness.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Psychiatric<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No mood changes, anxiety, depression, or suicidal ideation.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Endocrine<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No heat or cold intolerance, excessive thirst, or excessive urination.<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Hematologic and lymphatic<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No easy bruising, abnormal bleeding, or swollen lymph nodes.<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Allergic and immunologic<\/td>\n<td style=\"padding:12px 16px;color:#374151\">No known drug allergies and no history of anaphylaxis.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">That block covers most primary care and specialty visits. Repeating it word for word across a year of charts is what draws attention in a <a href=\"https:\/\/pabau.com\/blog\/medical-chart-audit\/\">chart audit<\/a>, though. Change the opening phrase, or add the one or two findings that fit the visit in front of you.<\/p>\n\n\n\n<h2 id=\"h-run-this-checklist-before-you-close-the-note\" class=\"wp-block-heading\">Run this checklist before you close the note<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Work down this list while the patient is still with you. Tick the systems that came back clean, and write out anything abnormal in full:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><input type=\"checkbox\"><\/input> Constitutional (fever, chills, weight changes, fatigue)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Eyes (vision changes, pain, discharge)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> ENT (hearing loss, sore throat, sinus symptoms)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Cardiovascular (chest pain, palpitations, leg swelling)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Respiratory (cough, shortness of breath, wheezing)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Gastrointestinal (nausea, abdominal pain, bowel changes)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Genitourinary (painful urination, frequency, blood in urine)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Musculoskeletal (joint or back pain, muscle weakness)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Skin (rash, lesions, color changes)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Neurological (headache, dizziness, numbness, tremor)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Psychiatric (mood, anxiety, suicidal thoughts)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Endocrine (heat or cold intolerance, thirst, urination)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Hematologic and lymphatic (bruising, bleeding, swollen nodes)<\/li>\n\n\n\n<li><input type=\"checkbox\"><\/input> Allergic and immunologic (allergies, anaphylaxis history)<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Fourteen ticks gives you a complete review. On specialty visits, go deeper on the systems your discipline lives in and keep the rest brief. Depth on the systems that matter is what a reviewer looks for.<\/p>\n\n\n\n<h2 id=\"h-three-specialty-variants-worth-keeping-on-file\" class=\"wp-block-heading\">Three specialty variants worth keeping on file<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Different settings weight the systems differently. These three variants are the ones practices ask for most.<\/p>\n\n\n\n<h3 id=\"h-primary-care\" class=\"wp-block-heading\">Primary care<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">\u00abPatient reports no recent fever, chills, or weight loss. Denies chest pain, palpitations, or shortness of breath. No cough. No nausea, vomiting, abdominal pain, or diarrhea. No painful or frequent urination. No joint pain or muscle weakness. No headache, dizziness, or fainting. No mood changes or anxiety. No rashes or lesions. No known drug allergies.\u00bb<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Practices running this at volume usually store it as a one-click phrase inside their <a href=\"https:\/\/pabau.com\/industry\/gp-clinic-software\/\">primary care software<\/a>, rather than in a separate document nobody opens.<\/p>\n\n\n\n<h3 id=\"h-mental-health-and-psychiatry\" class=\"wp-block-heading\">Mental health and psychiatry<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">\u00abPatient denies suicidal or homicidal ideation. No hallucinations or delusions. Sleep pattern normal. Appetite stable. No weight changes. Mood euthymic, affect appropriate. No tremor or neurological symptoms. Cardiovascular and respiratory systems reviewed and normal. No recent infections.\u00bb<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Psychiatric visits still need the medical systems covered, so keep a general panel in your <a href=\"https:\/\/pabau.com\/industry\/psychiatry-emr-software\/\">psychiatry EMR<\/a> alongside the mental health items.<\/p>\n\n\n\n<h3 id=\"h-cardiology\" class=\"wp-block-heading\">Cardiology<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">\u00abPatient specifically denies chest pain, pressure, or tightness at rest or with exertion. No palpitations or fainting. No shortness of breath lying flat or waking at night. No leg swelling or calf pain. No constitutional symptoms. Review of other systems unremarkable.\u00bb<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A clean cardiovascular ROS pairs well with a hands-on <a href=\"https:\/\/pabau.com\/blog\/circulation-assessment\/\">circulation assessment<\/a> when the history and the presentation do not quite agree.<\/p>\n\n\n\n<h2 id=\"h-what-the-ros-still-does-for-your-coding-in-2026\" class=\"wp-block-heading\">What the ROS still does for your coding in 2026<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">It no longer picks your office visit level. Since January 2021, CMS selects codes <a href=\"https:\/\/pabau.com\/procedure-codes\/cpt-code-99213\/\">99213<\/a> and its neighbors in the 99202 to 99215 range by medical decision-making or total time, not by history.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The old thresholds have not disappeared, though. Visit types outside that reform still use them, as do some payers. And the clinical reason for asking never depended on the code in the first place.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/uploads\/hipaa-compliance.png\" alt=\"HIPAA compliance settings in Pabau\"\/><figcaption class=\"wp-element-caption\"><em>Pabau keeps every ROS entry timestamped and tied to the clinician who wrote it, which is what an auditor asks for first.<\/em><\/figcaption><\/figure>\n\n\n\n<div style=\"height:35px;width:800px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">Here is how the history thresholds work where they still apply:<\/p>\n\n\n\n<table style=\"width:100%;border-collapse:separate;border-spacing:0;border-radius:12px;overflow:hidden;font-size:15px;line-height:1.5;margin:1.5em 0 2em;box-shadow:0 2px 12px rgba(0,0,0,0.08)\">\n<thead>\n<tr>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">History type<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">ROS systems required<\/th>\n<th style=\"background:#121D36;color:#fff;padding:14px 16px;text-align:left;font-weight:600;font-size:14px;letter-spacing:0.3px;border-bottom:2px solid #2BADD4\">Office visit level it supported before 2021<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Problem-focused<\/td>\n<td style=\"padding:12px 16px;color:#374151\">None required<\/td>\n<td style=\"padding:12px 16px;color:#374151\">99212<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Expanded problem-focused<\/td>\n<td style=\"padding:12px 16px;color:#374151\">1 system related to the chief complaint<\/td>\n<td style=\"padding:12px 16px;color:#374151\">99213<\/td>\n<\/tr>\n<tr>\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Detailed<\/td>\n<td style=\"padding:12px 16px;color:#374151\">2 to 9 systems<\/td>\n<td style=\"padding:12px 16px;color:#374151\">99214<\/td>\n<\/tr>\n<tr style=\"background:#F9FAFB\">\n<td style=\"padding:12px 16px;font-weight:600;color:#121D36\">Comprehensive<\/td>\n<td style=\"padding:12px 16px;color:#374151\">10 or more systems<\/td>\n<td style=\"padding:12px 16px;color:#374151\">99215<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n<p class=\"wp-block-paragraph\">Ten or more systems gives you a complete ROS. CMS&#8217;s 1997 guidelines let you record the pertinent positives and negatives individually, then write \u00aball other systems reviewed and normal\u00bb for the rest. That shorthand is permitted, as long as the pertinent findings are present.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A note carrying the shorthand and nothing else is the one that fails review. The consequence surfaces later, when a <a href=\"https:\/\/pabau.com\/blog\/clean-claim\/\">clean claim<\/a> turns into a denial you have to work.<\/p>\n\n\n\n<h2 id=\"h-where-the-ros-belongs-in-a-soap-note\" class=\"wp-block-heading\">Where the ROS belongs in a SOAP note<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">It sits in the S, the subjective section of a <a href=\"https:\/\/pabau.com\/blog\/soap-notes-examples\/\">SOAP note<\/a>. Place it after the history of present illness and before the past medical history. The order below is the one billing reviewers read fastest:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Open with the chief complaint.<\/strong> \u00abPatient presents with [complaint].\u00bb<\/li>\n\n\n\n<li><strong>Add the findings tied to that complaint.<\/strong> \u00abReports [symptom] but denies [related negatives].\u00bb<\/li>\n\n\n\n<li><strong>Then the wider ROS.<\/strong> \u00abReview of systems: patient denies fever, chills, weight loss, chest pain, shortness of breath, abdominal pain, painful urination, joint pain, rash, or neurological symptoms.\u00bb<\/li>\n\n\n\n<li><strong>Close with the background history.<\/strong> \u00abPMHx: [list]. FHx: [list]. SHx: [list].\u00bb<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">Problem first, then systems. That order mirrors clinical reasoning, so a reviewer follows the note without hunting. Practices that template the ROS inside their <a href=\"https:\/\/pabau.com\/features\/medical-records-management\/\">medical records system<\/a> stop retyping it altogether.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img decoding=\"async\" src=\"https:\/\/cdn.pabau.com\/cdn\/attachments\/pulse\/content-engine\/downloadable_template_article\/normal-review-of-systems\/comprehensive-emr-patient-record-management.webp\" alt=\"Pabau patient record and EMR view\"\/><figcaption class=\"wp-element-caption\"><em>Pabau&#8217;s patient record stores the review of systems with the rest of the note, so past negatives are one click away.<\/em><\/figcaption><\/figure>\n\n\n\n<div style=\"height:35px;width:800px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 id=\"h-five-ros-mistakes-that-surface-in-chart-reviews\" class=\"wp-block-heading\">Five ROS mistakes that surface in chart reviews<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Almost every ROS problem is procedural rather than clinical. Read these five before you sign the note:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Identical wording on every chart.<\/strong> Word-for-word repetition across a year of visits is the easiest pattern for a payer to spot.<\/li>\n\n\n\n<li><strong>An ROS that contradicts the history.<\/strong> The note says the patient came in coughing, then the respiratory line records no cough.<\/li>\n\n\n\n<li><strong>Systems counted but never named.<\/strong> \u00abTen systems reviewed\u00bb is a tally. It is not documentation.<\/li>\n\n\n\n<li><strong>Shorthand with nothing behind it.<\/strong> \u00abAll other systems reviewed and normal\u00bb needs individually documented findings to lean on.<\/li>\n\n\n\n<li><strong>Staff-recorded ROS with no sign-off.<\/strong> A nurse or the patient can record it, but the note has to show you reviewed it.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Four of those five are workflow fixes. The contradiction is the one that needs a human, so give the note a ten-second read-back before you sign.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Catching them at the chart costs you seconds. By the time the problem reaches <a href=\"https:\/\/pabau.com\/blog\/denial-management-in-healthcare\/\">denial management<\/a>, you are reworking a claim instead of seeing a patient.<\/p>\n\n\n\n<h2 id=\"h-how-pabau-automates-the-review-of-systems\" class=\"wp-block-heading\">How Pabau automates the review of systems<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The ROS usually gets captured twice. The patient answers on paper at the front desk, then someone retypes those answers into the note during or after the visit.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Practice management software like Pabau removes the second step. <a href=\"https:\/\/pabau.com\/features\/patient-intake-software\/\">Digital intake forms<\/a> collect the review of systems before the patient arrives, and the answers land straight in the client record. You open the note with the negatives already filled in.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">During the appointment, <a href=\"https:\/\/pabau.com\/features\/ai-medical-scribe\/\">Pabau Scribe<\/a>, our AI scribe, writes the conversation into the note. You confirm the systems that came back clean and expand the ones that did not.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">You end up with one version of the ROS, written once, stored with the appointment it belongs to. Wording stays consistent between clinicians, and nobody is retyping negatives at 7pm.<\/p>\n\n\n        <div id=\"book_a_demo\">\n            <div class=\"left-side\">\n                <div class=\"logo\">\n                    <img decoding=\"async\"\n                        src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Logo.svg\"\n                        alt=\"Logo\"\n                        loading=\"lazy\"\n                    \/>\n                <\/div>\n\n                <h3 class=\"heading\">\n                    Capture the review of systems once                <\/h3>\n\n                <p class=\"description\">\n                    Pabau&#8217;s digital intake forms and AI scribe pull review of systems answers straight into the client record. Your team stops retyping, and the wording stays consistent across clinicians.                <\/p>\n\n                <div class=\"button-group\">\n                    <a href=\"\/book-demo\/\" class=\"btn btn-scale-effect btn-cta-color btn-md\">\n                        <span class=\"btn-text\">Book a demo<\/span>\n                        <div class=\"btn-icon btn-icon-right\" aria-hidden=\"true\">\n                            <svg\n                                width=\"14\"\n                                height=\"12\"\n                                viewBox=\"0 0 14 12\"\n                                fill=\"none\"\n                                xmlns=\"http:\/\/www.w3.org\/2000\/svg\"\n                            >\n                                <path\n                                    d=\"M0.75 4.77295C0.335786 4.77295 0 5.10874 0 5.52295C0 5.93716 0.335786 6.27295 0.75 6.27295V5.52295V4.77295ZM13.2803 6.05328C13.5732 5.76039 13.5732 5.28551 13.2803 4.99262L8.50736 0.219648C8.21447 -0.073245 7.73959 -0.073245 7.4467 0.219648C7.15381 0.512542 7.15381 0.987415 7.4467 1.28031L11.6893 5.52295L7.4467 9.76559C7.15381 10.0585 7.15381 10.5334 7.4467 10.8263C7.73959 11.1191 8.21447 11.1191 8.50736 10.8263L13.2803 6.05328ZM0.75 5.52295V6.27295L12.75 6.27295V5.52295V4.77295L0.75 4.77295V5.52295Z\"\n                                    fill=\"currentColor\"\n                                ><\/path>\n                            <\/svg>\n                        <\/div>\n                    <\/a>\n                <\/div>\n            <\/div>\n\n            <div class=\"right-side\">\n                <img decoding=\"async\"\n                    src=\"https:\/\/pabau.com\/wp-content\/uploads\/2026\/01\/Home-Page-Concept-4.webp\"\n                    alt=\"Pabau practice management dashboard\"\n                    loading=\"lazy\"\n                \/>\n            <\/div>\n        <\/div>\n        \n\n\n<h2 id=\"h-conclusion\" class=\"wp-block-heading\">Conclusion<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The wording is the easy part. Getting the same wording into every chart, every time, without anyone retyping it, is what decides whether your documentation holds up.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">So pick one version of the template and put it where your team already works. Then spend the time you save on the pertinent findings. Those are the only part of the ROS a reviewer reads closely.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Doing that by hand takes discipline from every clinician on the schedule. <a href=\"https:\/\/pabau.com\/book-demo\/\">Book a demo<\/a> to see how Pabau captures the review of systems once and keeps it in the client record.<\/p>\n\n\n        <div id=\"expert_picks\">\n            <div class=\"header\">\n                                    <img decoding=\"async\" src=\"https:\/\/pabau.com\/wp-content\/uploads\/2025\/11\/Expert-Picks.svg\" alt=\"Continue your research\" height=\"42\" width=\"42\">\n                                <h3>Continue your research<\/h3>\n            <\/div>\n            <div class=\"content\">\n                                                            <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Need one system in more depth?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/constitutional-review-of-systems\/\">Constitutional review of systems<\/a> breaks down the symptoms and wording for that single system.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Working through annual wellness visits?<\/strong> <a href=\"https:\/\/pabau.com\/templates\/annual-physical-exam-checklist\/\">Annual physical exam checklist<\/a> covers the examination side of the same appointment.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Documenting a video consultation?<\/strong> <a href=\"https:\/\/pabau.com\/blog\/telemedicine-physical-exam\/\">Telemedicine physical exam<\/a> sets out what you can and cannot assess remotely.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Following up a positive urinary finding?<\/strong> <a href=\"https:\/\/pabau.com\/blog\/genitourinary-physical-exam\/\">Genitourinary physical exam<\/a> walks through the examination that comes next.<\/p>\n                        <\/div>\n                                                                                <div class=\"item\">\n                            <div>\n                                <svg width=\"20\" height=\"27\" viewBox=\"0 0 20 27\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <path\n                                        d=\"M18.6223 14.3857C19.1246 13.8975 19.1246 13.1045 18.6223 12.6162L12.1938 6.36621C11.6915 5.87793 10.8759 5.87793 10.3737 6.36621C9.87143 6.85449 9.87143 7.64746 10.3737 8.13574L14.6125 12.2529H2.28571C1.57455 12.2529 1 12.8115 1 13.5029C1 14.1943 1.57455 14.7529 2.28571 14.7529H14.6085L10.3777 18.8701C9.87545 19.3584 9.87545 20.1514 10.3777 20.6396C10.8799 21.1279 11.6955 21.1279 12.1978 20.6396L18.6263 14.3896L18.6223 14.3857Z\"\n                                        fill=\"#54B2D3\" \/>\n                                <\/svg>\n                            <\/div>\n                            <p><strong>Claims stopping before they reach the payer?<\/strong> <a href=\"https:\/\/pabau.com\/blog\/medical-claims-clearinghouse\/\">Medical claims clearinghouse<\/a> explains where they get held up and why.<\/p>\n                        <\/div>\n                                                <\/div>\n        <\/div>\n    \n\n\n<h2 id=\"h-frequently-asked-questions\" class=\"wp-block-heading\">Frequently asked questions<\/h2>\n\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1787040001001\"><h3 class=\"schema-faq-question\">What is the difference between the review of systems and the physical exam?<\/h3> <p class=\"schema-faq-answer\">The ROS is what the patient tells you. The physical exam is what you find yourself. Chest pain reported during questioning belongs in the ROS. A murmur you hear through a stethoscope belongs in the exam.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1787040001002\"><h3 class=\"schema-faq-question\">Do I have to repeat the whole ROS at every visit?<\/h3> <p class=\"schema-faq-answer\">No. CMS lets you review an ROS recorded at an earlier visit instead of taking it again. Note the date of the original, document anything that has changed since, and record that you reviewed it.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1787040001003\"><h3 class=\"schema-faq-question\">Can a nurse or the patient complete the review of systems?<\/h3> <p class=\"schema-faq-answer\">Yes. Ancillary staff can record it, and patients can complete it on an intake form. The clinician then has to show they reviewed it, by noting confirmation or by adding to what was recorded.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1787040001004\"><h3 class=\"schema-faq-question\">Does the ROS matter more in telehealth?<\/h3> <p class=\"schema-faq-answer\">Yes. Without a hands-on examination, what the patient reports carries most of your subjective data. Document each system you asked about, because a reviewer cannot infer it from an exam finding you were unable to make.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1787040001005\"><h3 class=\"schema-faq-question\">What should I do when a patient cannot give a review of systems?<\/h3> <p class=\"schema-faq-answer\">Document why. An unresponsive or severely cognitively impaired patient makes the ROS unobtainable, and CMS accepts that when the reason sits in the note. A blank section with no explanation does not carry the same weight.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>A normal review of systems documents 14 organ systems as negative findings. Read more for copy-paste wording, specialty variants and the 2021 E\/M rules.<\/p>\n","protected":false},"author":85,"featured_media":183122,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_yoast_wpseo_linkdex":"88","_yoast_wpseo_content_score":"60","_yoast_wpseo_is_cornerstone":"","_yoast_wpseo_keywordsynonyms":"[\"\",\"\",\"\",\"\",\"\",\"\"]","_yoast_wpseo_focuskw_text_input":"","_seo_original_html":"","footnotes":""},"categories":[4138],"tags":[1382],"class_list":["post-183124","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-templates","tag-template"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.2 (Yoast SEO v28.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Normal review of systems<\/title>\n<meta name=\"description\" content=\"A normal review of systems documents 14 organ systems as negative. 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