What should be included in a SOAP note ROS template for a normal patient?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: January 30, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

SOAP Note ROS Template for Normal Patient

A standardized Review of Systems (ROS) template for a normal patient should document all major organ systems systematically, with each system documented as "negative" or "denies" specific symptoms, ensuring comprehensive coverage while maintaining efficiency in clinical documentation.

Constitutional

  • Denies: fever, chills, night sweats, unintentional weight loss or gain, fatigue, malaise 1

Eyes

  • Denies: vision changes, eye pain, redness, discharge, photophobia, diplopia 1

Ears, Nose, Throat

  • Denies: hearing loss, tinnitus, ear pain, nasal congestion, rhinorrhea, epistaxis, sore throat, dysphagia 1

Cardiovascular

  • Denies: chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, syncope 1, 2
  • Heart rate: within normal limits (document specific value in bpm) 1
  • Blood pressure: within normal limits (document specific systolic/diastolic in mm Hg) 1

Respiratory

  • Denies: shortness of breath, dyspnea on exertion, cough, hemoptysis, wheezing 1, 2
  • Respiratory rate: within normal limits (document specific value in breaths/min) 1
  • Oxygen saturation: >95% on room air (document specific percentage) 1

Gastrointestinal

  • Denies: nausea, vomiting, diarrhea, constipation, abdominal pain, hematemesis, melena, hematochezia, changes in bowel habits 1

Genitourinary

  • Denies: dysuria, hematuria, urinary frequency, urgency, incontinence, nocturia 1

Musculoskeletal

  • Denies: joint pain, joint swelling, muscle pain, back pain, limitation of movement, trauma 3

Neurological

  • Denies: headache, dizziness, syncope, seizures, weakness, numbness, tingling, changes in coordination or gait 1
  • Level of consciousness: Alert and oriented (document using AVPU: Alert/Verbal/Painful/Unresponsive or GCS if indicated) 1

Psychiatric

  • Denies: depression, anxiety, mood changes, sleep disturbances, suicidal ideation, hallucinations 2

Endocrine

  • Denies: heat or cold intolerance, polydipsia, polyuria, changes in hair or skin 4

Hematologic/Lymphatic

  • Denies: easy bruising, bleeding, lymphadenopathy, history of blood clots 1

Allergic/Immunologic

  • Denies: seasonal allergies, hives, recurrent infections 2

Skin

  • Denies: rashes, lesions, changes in moles, pruritus 1

Documentation Requirements

Temperature: Document specific value in degrees Celsius or Fahrenheit with method (oral/rectal/axillary/tympanic) 1

Pain assessment: Document using standardized pain scale (0-10) if applicable 1

All systems reviewed and negative except as noted above - this statement should be included to confirm comprehensive review 5

Critical Documentation Pitfalls

  • Never document "ROS negative" or "ROS non-contributory" without specifying individual systems reviewed 5, 6
  • Document specific vital sign values rather than "within normal limits" alone 1
  • Ensure consistency between ROS documentation and physical examination findings 3, 5
  • Update ROS at each encounter rather than copying forward from previous visits 5
  • Include timing notation for when ROS was obtained 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Chronic Shortness of Breath

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Myxedema Coma Precipitating Factors

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

The essential SOAP note in an EHR age.

The Nurse practitioner, 2016

6
Research

Assessment of SOAP note evaluation tools in colleges and schools of pharmacy.

Currents in pharmacy teaching & learning, 2017

Related Questions

What is the proper format for writing a SOAP (Subjective, Objective, Assessment, Plan) note?
What should be included in a SOAP (Subjective, Objective, Assessment, Plan) note template?
What should be included in a SOAP note for a patient?
Are you able to write SOAP (Subjective, Objective, Assessment, Plan) notes?
What is the purpose of the assessment phase in SOAP?
What is the likelihood of active tuberculosis (TB) in a patient with ground glass opacities on a computed tomography (CT) scan of the lungs, particularly in those from regions with high TB prevalence or with a history of exposure to TB?
What is the first-line treatment for patients with osteoporosis, particularly those at high risk of fractures with a history of previous fractures?
What is the initial request and workup for a patient presenting with hematochezia (passage of fresh blood per anus), considering their age, past medical history, and potential underlying causes such as diverticulosis, angiodysplasia, inflammatory bowel disease, or colorectal cancer?
In a patient with a history of heavy smoking and lung cancer, which malignancy is more likely to metastasize to the liver, gastric or lung cancer?
What is the cause of neurologic symptoms in a patient with chronic obstructive pulmonary disease (COPD) who develops confusion, lethargy, and seizure after starting treatment with high flow oxygen, inhaled bronchodilators, systemic corticosteroids, and intravenous azithromycin (azithromycin) for a COPD exacerbation?
Are Coenzyme Q10 (CoQ10) supplements beneficial for a 58-year-old, otherwise healthy male for mitochondrial health?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question