Review of Systems in the ED

[Chromatid]

Colleagues,
4th yr on sub I in ED. Yesterday had a pt with chest pain. I do my H&P, present to resident, talk about plan, get orders going, present to attending. Then I am done charting and the resident comes up to me and says I need to have charted more on my review of systems and that need to have 8 systems covered with 2 or more symptoms checked off or ruled out in order to get the proper billing. Then the attending and resident talked about how everyone has
their "list" for ROS (headache, chills, wt loss, eye pain, ear pain, sore throat... etc). I ended up going back in the room and basically listing things off that I hadn't covered. I typically like to only ask questions when I am seeking something from them or they will alter how I would treat a patient so I have trouble with the idea of going back in the room of a chest pain patient and asking, any chills at home? sore throat (ok, i know, could be a gerd sx causing CP)? headache? Probably should just suck it up and make my list. Just looking for advice about how you guys go about your ROS. I guess another thing is how I am suppose to interpret whether pt has whatever I am asking them about, i.e. You have a headache with this? "Yes, sometimes I get headaches". Do you have any weakness? "yes, at the end of a long day". I mean, do I interpret stuff like that as a yes or no. My fear with the ROS is suddenly having this chart where the patient looks a lot sicker than they actually are and causing me to order unnecessary tests to CMA. Gonna ask about this on my next shift as well.
Thanks preemptively for any advice given.

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[strongboy2005]

I've always thought the point of an ROS was to cover every system to be sure that you weren't missing something. If you're only asking ROS questions specific to the complaint (e.g., cardiac, pulmonary, and abdominal for chest pain) then you're not really doing a review of systems.

 

[Arcan57]

If it's specific to the chief complaint, then it's not ROS it's associated symptoms. You don't need to have two points check off on each system, only one. If you chart with T-sheets, an interesting fact is that the ROS box for most of the T-sheets will not be sufficient to generate a level 5 (the highest coding level excluding critical care) even with every system marked unless "otherwise negative except per HPI" is also marked.

 

[Haemr Head]

I suspect that the department is pushing the attendings and residents to meet the minimum criteria for "comprehensive care" needed to bill levels 4&5 E&M codes. However, the number is 10, not 8.

E&M stands for evaluation and management. It is the reimbursement system used by CMS, and pushed through years ago by the Internal Medicine lobbyists. You also need to document the past history, family, and social history. You need a certain number of systems on the physical exam, and at least 4 criteria on the medical decision making if you want to hit Big Casino, a level 5.

If you collect 10 systems for an ankle sprain and exercise creative writing in the MDM you could bill it as a level 4. However either the payer will block it or someday, somewhere, the OIG will come knocking on your door for health care fraud.

Checking diligently on every system may uncover an unexpected life threat just as blind squirrels do find nuts. But it's really mainly a bit of bureaucratic mischief that we suffer to get paid for the work we do.

 

[Indryd]

Thanks preemptively for any advice given.

HPI for CP easily covers level 5 ROS and takes at most 2 minutes in a normal patient and maybe 5 in a rambling or distressed patient.

CONST: Fevers, diaphoresis
PULM: Cough, pleuritic pain, hemoptysis, SOB, DOE (or put in CV if you like)
CV: CP, palpitations, syncope (or call it neuro if you like) edema, SOB, DOE (or put in resp if you like)
GI: Nausea, vomiting, abd pain
NEURO: Dizziness, syncope, weakness
ID: Recent illness, sick contacts

I would say if you did not cover 90% of these things then you did not take a sufficient HPI for CP. This is assuming of course that the patient isn't having a STEMI or coughing up frank blood or syncopizing right in front of you.

Most presentations can fit into level 5 just on HPI without having to ask irrelevant questions. Obviously a drunk drying out or a drug-seeker or whatever would be a stretch to get a billable ROS, but most of the time no biggie.

 

[quinsy]

Positive ROS doesn't mean the patient is sick, "positive ROS" is code for not sick at all. 🙂 but if the answer to these questions is actually yes then aren't you doing an inadequate history if you're trying not to ask about them because you don't want to know?

After asking any particularly pertinent ROS during the main portion of the history, I say: "Is anything else bothering you today? Eyes, ears, nose, throat problems? Chest pain, shortness of breath, nausea or vomiting?" Ask a few questions like that while you're doing the physical exam and you'll cover the review of systems without wasting any time. On all but the most straightforward patients I can easily get in the 10 point ROS for a level 5.

It's the emergency department, not the primary care office, you don't have to order tests based on what you find out unless you think they need an emergent workup. If they're chronic or irrelevant, just mark them down and move on, i.e. "she does have chest pain but it is chronic for the past 5 years and has not changed." or just "headache - chronic". You will find that if you ask about fever or chills, a huge number of people will answer "yes, I've been feeling hot" or "I've been feeling cold/having chills", but that doesn't mean you have to get blood cultures or something. I just put "subjective chills" or "subjectively feeling hot" and if they're afebrile and there for an ankle sprain, I promptly forget about it.

 

[The White Coat Investor]

My ROS goes like this:

Anything else going on that's new? Fever, headache, trouble seeing, hearing, or swallowing, chest pain, cough, shortness of breath, abdominal pain, vomiting, diarrhea, problems with urination, rashes, weakness or numbness, or psychiatric problems?

If you finish with psychiatric problems, they always say "Oh no, doc, just the elbow pain we talked about." I check the little box on the template and off we go.

 

[Cerberus]

HPI for CP easily covers level 5 ROS and takes at most 2 minutes in a normal patient and maybe 5 in a rambling or distressed patient.

CONST: Fevers, diaphoresis
PULM: Cough, pleuritic pain, hemoptysis, SOB, DOE (or put in CV if you like)
CV: CP, palpitations, syncope (or call it neuro if you like) edema, SOB, DOE (or put in resp if you like)
GI: Nausea, vomiting, abd pain
NEURO: Dizziness, syncope, weakness
ID: Recent illness, sick contacts

I would say if you did not cover 90% of these things then you did not take a sufficient HPI for CP. This is assuming of course that the patient isn't having a STEMI or coughing up frank blood or syncopizing right in front of you.

Most presentations can fit into level 5 just on HPI without having to ask irrelevant questions. Obviously a drunk drying out or a drug-seeker or whatever would be a stretch to get a billable ROS, but most of the time no biggie.

Meh, the more CP cases you see, the more you realize you could probably diagnose 90% of them accurately without doing anything more than reading the triage note, vs, pmhx, meds, and looking at the ekg/labs.

 

[Chromatid]

OP here...
To follow up, talked with attendings about it and they really brushed as being a route to a level 5 billing. Clearly there are instances where particular aspects of the ROS, or the entire ROS is high yield and others where it is not. i.e. the groin strain guy I had yesterday that happened after he fell, that felt exactly like last time strained his groin (asking about uti sx, cp sx, etc.) why he came into the ed I will never know).
I guess as a student I have yet to develop the skills to differentiate what I think should be important and what is not. I frequently encounter pts who answer yes to much of the ROS but then when I ask if that individual complaint would be enough to bring them into the ED alone they typically say no. Is a ROS element only positive if it is something that is occurring now or with their presenting complaint, that is my main issue, how to tell whether or not it is pertinent enough to be listed as positive.
Lastly, ROS did turn out useful for a young female pt with a complaint of HA (def a complaint where i feel the entire ROS is useful). Got to GU stuff.. vaginal discharge +, urinary symptoms+, pain with sex, didn't even mention that through the entire history despite asking LMP, period regularity, contraceptive use.
this is how I've boiled down my general ros (say on otherwise healthy guy who came in because a injury during soccer game or something)
fever, chills, night sweats, headaches, dizziness, fainting, eye pain, blurry vision, ear pain, ringing in ears, sore throat, runny nose, chest pain, palpitations, sob, cough, ab pain, n/v/d, pain with urination, discharge, back neck joint muscle pain, new skin rashes or marks, drug etoh abuse..

 

[Venko]

My ROS goes like this:

Anything else going on that's new? Fever, headache, trouble seeing, hearing, or swallowing, chest pain, cough, shortness of breath, abdominal pain, vomiting, diarrhea, problems with urination, rashes, weakness or numbness, or psychiatric problems?

If you finish with psychiatric problems, they always say "Oh no, doc, just the elbow pain we talked about." I check the little box on the template and off we go.

I totally agree with this and find it extremely helpful. Also, really have to stress the "new" part 🙂

 

[deleted109597]

Meh, the more of any kind of patient you see, the more you realize you could probably diagnose 90% of them accurately without doing anything more than reading the triage note, vs, pmhx, meds, and looking at the ekg/labs.

Fixed

 

[Indryd]

Meh, the more CP cases you see, the more you realize you could probably diagnose 90% of them accurately without doing anything more than reading the triage note, vs, pmhx, meds, and looking at the ekg/labs.

Yes, true. But it's the other 10% that EM is all about and why hospitals need doctors in the ED.