Useless ROS Questions

[turkeyjerky]

It's been my experience that many customary review of systems questions have such a low discriminatory value to make them essentially useless, and I was wondering about others' opinions on this. In particular, I've found that asking about blurry vision results in a nearly 100% positive response rate, which, after a few minutes of probing reveals that the patient had blurry vision two days ago when they weren't wearing their contacts. Another one is chills--I don't think I've had a negative response to this all winter, "yeah doc, it was really cold last night and I needed an extra blanket" or "I did have a chill go up my spine when the back pain started". Unfortunately, I've been having a difficult time breaking myself of the habitual saying 'fevers or chills'. Anyone have other examples?

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[The White Coat Investor]

Headache is universally positive among ED patients. However, hallucinations is not, nor is genital lesions. So always ask your questions like this:

Any chest pain, shortness of breath, belly pain, or genital lesions? Any rashes, headaches, weakness, numbness, or hallucinations? Then you always get "No"s and can move on to what actually matters for patient care instead of billing.

 

[namethatsmell]

Another one is chills--I don't think I've had a negative response to this all winter, "yeah doc, it was really cold last night and I needed an extra blanket" or "I did have a chill go up my spine when the back pain started". Unfortunately, I've been having a difficult time breaking myself of the habitual saying 'fevers or chills'. Anyone have other examples?

Whenever anybody tells me they have "chills" I always push them to see if they were actually shaking or if they just felt cool.

One thing that gets me is chest pain...I actually don't ask about pain I ask about chest discomfort because about 98% of my patients have DM and the rest are the kind who say "chest pain? nah doc I don't have pain." But if you probe a bit deeper you get "oh yeah it does feel like an elephant is sitting on my heart." While I've found this approach helpful it also gets me plenty of "whenever its about 68 degrees outside with a northwesterly wind I get this aweful pain in my chest. Especially on Tuesdays."

 

[Apollyon]

Headache is universally positive among ED patients. However, hallucinations is not, nor is genital lesions. So always ask your questions like this:

Any chest pain, shortness of breath, belly pain, or genital lesions? Any rashes, headaches, weakness, numbness, or hallucinations? Then you always get "No"s and can move on to what actually matters for patient care instead of billing.

I remember a few years ago when you said something with those that included "diabetes", and I replied, "Yeah, doc, I've been having some diabetes recently". It just made me chuckle here at work for a minute.

Ah, here it is!

 

[killerleaf]

From a weird patient's perspective: Please be specific when you ask me about past chest pain. I have arthritis in my sternum; (sorry I can't remember the real name for it) and sometimes, yes, I do have chest pain. Hurts like a b****. Can't breathe when it flares up. If you have been nice to me, I will see the concern on your face and immediatly tell you about the arthritis. If you have been brusque, or just plain rude, then we might draw it out just a little...."yes, I have had chest pain, so bad I could not breathe for the pain...." hehehe

 

[dotcb]

It's not the questions that are a problem - it's how you ask them that matters in whether the answers are useful or not. Timing, etc.

 

[Hamhock]

Headache is universally positive among ED patients. However, hallucinations is not, nor is genital lesions. So always ask your questions like this:

Any chest pain, shortness of breath, belly pain, or genital lesions? Any rashes, headaches, weakness, numbness, or hallucinations? Then you always get "No"s and can move on to what actually matters for patient care instead of billing.

I do something similar and lead with a 'genital lesions' equivalent to get them in the 'No, no, no' rhythmn. Do you have difficulty talking, inability to move your arms or legs, etc.? Are you vomiting blood, started having blood in your stools, and so on?

The best technique might be to "bookend" a rapid fire sequence of ROS with something like genital lesions and hearing voices...

And never ask a patient with an unrelated CC about back pain, blurry vision, chills, dizziness, bloating, or fatigue...

HH

 

[Arcan57]

URI pts who answer yes to difficulty breathing when they really mean they have significant nasal congestion. I haven't found a good way to disarticulate rhinitis from pulmonary issues without at least one additional back and forth with the patient

 

[GTP]

URI pts who answer yes to difficulty breathing when they really mean they have significant nasal congestion. I haven't found a good way to disarticulate rhinitis from pulmonary issues without at least one additional back and forth with the patient

I just say shortness of breath/short winded vs stuffy nose

 

[Arcan57]

I just say shortness of breath/short winded vs stuffy nose

But that still requires clarification from the patient if they answer yes to shortness of breath to determine that it's not from nasal congestion. And it's also quite possible they have both symptoms so asking an either/or also requires clarification. You could ask "do you have shortness of breath not caused by a stuffy nose?" but that's a long question that requires the patient to process a 2 steps and unless your tone is impeccable comes off as being super condescending.

 

[GTP]

But that still requires clarification from the patient if they answer yes to shortness of breath to determine that it's not from nasal congestion. And it's also quite possible they have both symptoms so asking an either/or also requires clarification. You could ask "do you have shortness of breath not caused by a stuffy nose?" but that's a long question that requires the patient to process a 2 steps and unless your tone is impeccable comes off as being super condescending.

Lol. I see what u mean. But I usually do my ROS in a head to toe manner. So I ask about stuffy nose/bloody nose/changes in smell about 2 min before getting to lungs and asking about SOB/wheezing. I guess I've just never had a problem with it. Maybe one day I'll get the odd patient

 

[turkeyjerky]

Headache is universally positive among ED patients. However, hallucinations is not, nor is genital lesions. So always ask your questions like this:

Any chest pain, shortness of breath, belly pain, or genital lesions? Any rashes, headaches, weakness, numbness, or hallucinations? Then you always get "No"s and can move on to what actually matters for patient care instead of billing.

One time I did this, but for some reason "depression" came out of my mouth; the next five minutes consisted of her detailing how miserable her life has been the past 2 weeks, and redirection was impossible. Never again!

I like the addition of genital lesions, but I'm not sure its worth the risk of having to add on a pelvic exam. But for males, I could see adding this to my repertoire (a lot less common to have a pan-positive ROS w/ men though).

 

[deleted547339]

Lol. I see what u mean. But I usually do my ROS in a head to toe manner. So I ask about stuffy nose/bloody nose/changes in smell about 2 min before getting to lungs and asking about SOB/wheezing. I guess I've just never had a problem with it. Maybe one day I'll get the odd patient

You spend two minutes on ROS from nose to chest? You're doing it wrong.....

 

[GTP]

You spend two minutes on ROS from nose to chest? You're doing it wrong.....

Nose, ear, Mouth, throat, cardiac, then lungs. In a perfect world i want to say one minute, but these days throat yields positive ROS and patients aren't kind enough to just say yes or no and then let you move on. I'm also still a med student so im not good at cutting people off yet when they go on rants, So yeah unfortunately 1-2 min. Cardiac is hard too cuz i cant just ask if they get chest pain/palpitations. I have to say irregular heart beat or sensation of a pounding heart lol.

 

[VA Hopeful Dr]

But that still requires clarification from the patient if they answer yes to shortness of breath to determine that it's not from nasal congestion. And it's also quite possible they have both symptoms so asking an either/or also requires clarification. You could ask "do you have shortness of breath not caused by a stuffy nose?" but that's a long question that requires the patient to process a 2 steps and unless your tone is impeccable comes off as being super condescending.

Urgent Care work has taught me to ask "Are you having trouble catching your breath?".

 

[Hamhock]

But that still requires clarification from the patient if they answer yes to shortness of breath to determine that it's not from nasal congestion. And it's also quite possible they have both symptoms so asking an either/or also requires clarification. You could ask "do you have shortness of breath not caused by a stuffy nose?" but that's a long question that requires the patient to process a 2 steps and unless your tone is impeccable comes off as being super condescending.

With the urgent care type patients, I will sometimes try to get positive ROS answers allowing me to show empathy (ohh, I bet all that congestion and tightness is causing you to have difficulty breathing, right? It's up there (points to sinuses) not down in your lungs, right? which is asked while pretending to listen to heart sounds) ...this is followed with questions that will clearly give ROS negative answers as above.

This is not a court of law, leading the witness is fair game -- and the ROS is just a game.

HH

 

[WilcoWorld]

I like and use the above techniques, but there are a couple of other things worth noting:

-You only need 2 ROS for a level 4 chart. Only the level 5's need a "complete" 10-point ROS. It's rare that I won't cover at least 2 systems in any HPI (heck, asking about a rash covers skin, heme & allergy), so for the majority of visits the ROS is a non-issue.

-You don't have to document everything the patient says. If they report that their vision went blurry 2 months ago, but that it's been normal since, you can just omit that. Alternatively, sometimes I'll write "denies any current visual disturbance". Put another way - doctors aren't simply there to transcribe a patient's statements - we're there to interpret and synthesize what they tell us.

 

[The White Coat Investor]

This is not a court of law, leading the witness is fair game -- and the ROS is just a game.

This is key. ROS is not about medical care or even liability. It's about billing. Everything that I thought was important to ask the patient for either of those I already asked while taking the HPI.

I also find doing ROS while you do the exam helps speed things up. Plus it distracts them which helps me sort out subjective/objective tenderness and weird neuro stuff.

 

[The White Coat Investor]

Nose, ear, Mouth, throat, cardiac, then lungs. In a perfect world i want to say one minute, but these days throat yields positive ROS and patients aren't kind enough to just say yes or no and then let you move on. I'm also still a med student so im not good at cutting people off yet when they go on rants, So yeah unfortunately 1-2 min. Cardiac is hard too cuz i cant just ask if they get chest pain/palpitations. I have to say irregular heart beat or sensation of a pounding heart lol.

A minute? It's one or two sentences. Why does it take a minute? It's only a minute if you are doing it all wrong. I ask the ROS as I stand up after finishing any important history and begin the exam (if I haven't already). It goes like this:

Anything else going on NEW TODAY that I should be aware of? Any loss of vision (1), ear pain (2), headache (3), new rashes (4,5,6), chest pain (7), shortness of breath (8), vomiting (9), pain with urination (10), or hallucinations (11)?

If they say "No", you're done. That's gotta be less than 10 seconds. It takes me that long to put the otoscope cover on. If they say yes, you can explore it a bit and determine (at least 90% of the time) that it doesn't matter at all.

But you're absolutely right that want to use the "highly discriminating" stuff, not the vague stuff.

Instead of nausea- ask about vomiting.
Instead of headache, ask about paralysis on one side of their body.
Instead of depression, ask about suicide attempts this week.
Instead of diarrhea, ask about rectal bleeding
Instead of trouble hearing, ask about ear pain
Instead of low back pain, ask about new joint dislocations

Might as well make it fun, since it's just a billing game.

Never ask about stuff like dizziness, fatigue, night sweats, nausea, headaches, low back pain or any other complaint you hate to work up in the ED. Only ask about stuff you might actually do something about.

 

[GTP]

A minute? It's one or two sentences. Why does it take a minute? It's only a minute if you are doing it all wrong. I ask the ROS as I stand up after finishing any important history and begin the exam (if I haven't already). It goes like this:

Anything else going on NEW TODAY that I should be aware of? Any loss of vision (1), ear pain (2), headache (3), new rashes (4,5,6), chest pain (7), shortness of breath (8), vomiting (9), pain with urination (10), or hallucinations (11)?

If they say "No", you're done. That's gotta be less than 10 seconds. It takes me that long to put the otoscope cover on. If they say yes, you can explore it a bit and determine (at least 90% of the time) that it doesn't matter at all.

But you're absolutely right that want to use the "highly discriminating" stuff, not the vague stuff.

Instead of nausea- ask about vomiting.
Instead of headache, ask about paralysis on one side of their body.
Instead of depression, ask about suicide attempts this week.
Instead of diarrhea, ask about rectal bleeding
Instead of trouble hearing, ask about ear pain
Instead of low back pain, ask about new joint dislocations

Might as well make it fun, since it's just a billing game.

Never ask about stuff like dizziness, fatigue, night sweats, nausea, headaches, low back pain or any other complaint you hate to work up in the ED. Only ask about stuff you might actually do something about.

Yeah I do it like that. Maybe it doesn't take a minute then. Idk. I didn't time myself. I just guess-stimated. The only point I have tried to make was that congestion/dyspnea haven't been confused by any of my patients so far because i ask them separately and with a notable delay in between nose and lung ROS.

 

[Birdstrike]

.

 

[Charlie Hustle]

A minute? It's one or two sentences. Why does it take a minute? It's only a minute if you are doing it all wrong. I ask the ROS as I stand up after finishing any important history and begin the exam (if I haven't already). It goes like this:

Anything else going on NEW TODAY that I should be aware of? Any loss of vision (1), ear pain (2), headache (3), new rashes (4,5,6), chest pain (7), shortness of breath (8), vomiting (9), pain with urination (10), or hallucinations (11)?

If they say "No", you're done. That's gotta be less than 10 seconds. It takes me that long to put the otoscope cover on. If they say yes, you can explore it a bit and determine (at least 90% of the time) that it doesn't matter at all.

But you're absolutely right that want to use the "highly discriminating" stuff, not the vague stuff.

Instead of nausea- ask about vomiting.
Instead of headache, ask about paralysis on one side of their body.
Instead of depression, ask about suicide attempts this week.
Instead of diarrhea, ask about rectal bleeding
Instead of trouble hearing, ask about ear pain
Instead of low back pain, ask about new joint dislocations

Might as well make it fun, since it's just a billing game.

Never ask about stuff like dizziness, fatigue, night sweats, nausea, headaches, low back pain or any other complaint you hate to work up in the ED. Only ask about stuff you might actually do something about.

This has been really helpful. Thanks for your input.

I'm a current third year, and as my EM electives are coming up fast I'd like some feedback. How much time should I be spending in the room with the patient before presenting to my resident/attending? I realize there's a fine line between being thorough/comprehensive and just going overboard, and I just wanted to hear from some of the attendings out there regarding your expectations. I've been trying to streamline things as you've described while doing admission H&P's while rotating on some of my other services, and while I understand that the two are different beasts, it still seems like I'm taking an awfully long time.

Thanks.

 

[GTP]

This has been really helpful. Thanks for your input.

I'm a current third year, and as my EM electives are coming up fast I'd like some feedback. How much time should I be spending in the room with the patient before presenting to my resident/attending? I realize there's a fine line between being thorough/comprehensive and just going overboard, and I just wanted to hear from some of the attendings out there regarding your expectations. I've been trying to streamline things as you've described while doing admission H&P's while rotating on some of my other services, and while I understand that the two are different beasts, it still seems like I'm taking an awfully long time.

Thanks.

Yeah I'd like to hear this too as I'm in the same boat. I just read this post again. I think it's because I ask three things per system. Ie nose congestion/nose bleeds/changes in smell. It seems like you just ask one thing per system. Maybe that's why I take so long.

 

[namethatsmell]

How much time should I be spending in the room with the patient before presenting to my resident/attending? I realize there's a fine line between being thorough/comprehensive and just going overboard, and I just wanted to hear from some of the attendings out there regarding your expectations.

Your goal should be 10, maybe 12 mins at most. You're don't want their life story and there isn't usually a point to being there for more time since you'll almost certainly miss things even if your were there for 20+ mins. This isn't because you're a bad student, you just won't have enough experience to know what to ask (and no worries, this still happens from time to time to me too...you'll get better as you move through training).

 

[The White Coat Investor]

Yeah I'd like to hear this too as I'm in the same boat. I just read this post again. I think it's because I ask three things per system. Ie nose congestion/nose bleeds/changes in smell. It seems like you just ask one thing per system. Maybe that's why I take so long.

That's a good question. How many things per system do you need to bill? My assumption was always just one, but perhaps that isn't true. This site:

http://emuniversity.com/ReviewofSystems.html

suggests that's true.

The Review of Systems (ROS) is an inventory of specific body systems performed by the physician in the process of taking a history from the patient. The ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. In theory, the ROS may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention to the physician. The rules for documenting the ROS are identical for both the 1995 and 1997 E/M guidelines.

There are fourteen individual systems recognized by the E/M guidelines:

1. Constitutional (e.g., fever, weight loss)
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic

E/M University Coding Tip: There are no specific rules about how much to ask the patient about each system. This is left up to the discretion of the individual examiner.

There are three levels of ROS recognized by the E/M guidelines:

1. Problem Pertinent ROS : Requires review of ONE system related to current problem(s)
2. Extended ROS: Requires review of TWO to NINE systems
3. Complete ROS: Requires review of at least 10 systems

E/M University Coding Tip: When documenting the ROS , it is not necessary to list each system individually. It is acceptable to document a few pertinent positive or negative findings and then say: “All other systems were reviewed and are negative.”


If it's up to my discretion, I choose one.

 

[GTP]

That's a good question. How many things per system do you need to bill? My assumption was always just one, but perhaps that isn't true. This site:

http://emuniversity.com/ReviewofSystems.html

suggests that's true.

The Review of Systems (ROS) is an inventory of specific body systems performed by the physician in the process of taking a history from the patient. The ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. In theory, the ROS may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention to the physician. The rules for documenting the ROS are identical for both the 1995 and 1997 E/M guidelines.

There are fourteen individual systems recognized by the E/M guidelines:

1. Constitutional (e.g., fever, weight loss)
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic

E/M University Coding Tip: There are no specific rules about how much to ask the patient about each system. This is left up to the discretion of the individual examiner.

There are three levels of ROS recognized by the E/M guidelines:

1. Problem Pertinent ROS : Requires review of ONE system related to current problem(s)
2. Extended ROS: Requires review of TWO to NINE systems
3. Complete ROS: Requires review of at least 10 systems

E/M University Coding Tip: When documenting the ROS , it is not necessary to list each system individually. It is acceptable to document a few pertinent positive or negative findings and then say: “All other systems were reviewed and are negative.”

If it's up to my discretion, I choose one.

Cool. My ROS will now by significantly shorter. Thanks!! Just in time for CS/PE

 

[golghiapparatus]

Cool. My ROS will now by significantly shorter. Thanks!! Just in time for CS/PE

If you're refering to Step 2CS, keep in mind that they aren't operating in the same universe as the billers referenced above (in fact, they may not be operating in the same universe as any even moderately sane person)... so, for CS, just do what they tell you to do and play THAT game.

 

[scummie]

If you're refering to Step 2CS, keep in mind that they aren't operating in the same universe as the billers referenced above (in fact, they may not be operating in the same universe as any even moderately sane person)... so, for CS, just do what they tell you to do and play THAT game.

Yes, definitely. You will be docked for sure if you don't include that information. Wait until the test is over and you've passed to start using your brand new ROS. 🙂

 

[GTP]

Thanks for the advice guys