Full Review of Systems

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Constitutional:  No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise
ENT/Mouth:  No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes:  No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular:  No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations
Respiratory:  No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal:  No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice
Genitourinary:  No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria, No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy
Musculoskeletal:  No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History
Skin:  No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge
Neuro:  No Weakness, No Numbness, No Paresthesias, No Loss of Consciousness, No Syncope, No Dizziness, No Headache, No Coordination Changes, No Recent Falls
Psych:  No Anxiety/Panic, No Depression, No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH, No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns
Heme/Lymph:  No Bruising, No Bleeding, No Transfusions History, No Lymphadenopathy
Endocrine:  No Polyuria, No Polydipsia, No Temperature Intolerance
  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.