Review of Systems Documentation by Nurse Practitioners
No, the Review of Systems (ROS) should not contain objective findings observed by the nurse practitioner—the ROS is specifically for documenting subjective symptoms reported by the patient, while objective observations belong in the Physical Examination section of the note.
Understanding the Distinction
The Review of Systems is fundamentally a patient-reported inventory of symptoms across body systems. This is a critical distinction in medical documentation:
- ROS = Subjective: What the patient tells you they are experiencing (e.g., "patient denies chest pain," "reports occasional headaches") 1
- Physical Exam = Objective: What you observe, measure, or elicit during examination (e.g., "lungs clear to auscultation," "no peripheral edema noted") 2
Proper Documentation Practices for Nurse Practitioners
Where to Document Observations
Objective findings must be documented in the Physical Examination section, not the ROS, regardless of who performs the examination 2. The American College of Physicians emphasizes that documentation should accurately reflect what occurred during the patient encounter and maintain clear distinctions between subjective and objective data 1.
Acceptable Use of Templates and Efficiency Tools
For both ROS and Physical Exam sections, nurse practitioners can appropriately use:
- One-click templates and macros for normal findings, as these replicate what would otherwise be handwritten and are acceptable time-saving functions as long as the final documentation accurately reflects the encounter 1, 2
- Standardized terminology for documenting normal or expected findings, which is consistent with traditional paper-based documentation practices 1, 2
Critical Documentation Principles
The final signed documentation must accurately reflect what actually occurred during the encounter, regardless of the efficiency tools used 1. Key principles include:
- Documentation should be brief, thoughtful, and efficiently convey findings and thought processes 1
- Avoid "cloning" where entries are worded exactly like previous entries, as this can be considered misrepresentation by CMS 1
- When data is pulled from another location in the chart, the source should be indicated 1
Common Pitfalls to Avoid
Do not mix subjective and objective data in either section, as this creates confusion and can undermine the credibility of the entire record 1. Specifically:
- Placing vital signs (objective) in the ROS section
- Documenting physical examination findings (objective) as part of the systems review
- Using excessive templates that standardize away the unique aspects of each patient encounter 1
Team Documentation Considerations
When other team members (such as medical assistants) record objective measures during patient intake, these should not be redundantly documented unless adding new clinical context 1. The EHR should recognize that if height, weight, and blood pressure are already documented, additional redundant documentation is unnecessary 1.