Review of Systems

The Review of Systems encounter section is an optional section that can be applied to the encounter outline. This can be used to help document a Review of Systems regarding the visit within an encounter.

Add a Review of Systems - Flowsheet

The Review of Systems encounter section points to a specific flowsheet configured in the system. This flowsheet can be customized for your needs. A configured flowsheet named Review of Systems in the flowsheet editor will display the data capture fields in the encounter Review of Systems section. Using the Review of Systems flowsheet allows your system to capture unique or custom information for your practice to document in an encounter within the Review of Systems encounter section.

To utilize a flowsheet method in Review of Systems, a flowsheet named Review of Systems must exist with contents.

NOTE: Review of System fields (when in expanded mode) reflect any chief complaint protocol(s) selected. Otherwise, if no chief complaint protocol is designated on the encounter, the Review of Systems section will default to offering our standard Review of Systems flowsheet questions. For more information on chief complaint protocols, please see separate guide Encounter Protocols.

Copy from Previous Exam

Within the Review of Systems encounter section, there is an icon that offers Copy from Previous Exam functionality.

The Copy from Previous Exam icon pops up a window to allow you to select Review of Systems field data that you wish to copy from the chart’s prior encounter(s) to this current encounter.

For more detailed information, please refer to guide Copy from Previous Exam.

Macros

If utilizing a Review of Systems flowsheet, library macros offered in the Review of Systems encounter section are a way to quickly insert predefined text with minimal user input depending on what library your encounter is set to or the Review of Systems section library that is set to.

For additional information on configuring and utilizing macros that can be utilized within the Review of Systems encounter section, please see separate guide Macros and/or Libraries.

Delete / Edit / View Review of Systems Captured Data

You can edit, delete, add to, or view the specific documented Review of Systems data from the encounter section.

Hover Options

Once Review of Systems data has been documented, one can edit, add to, or delete data for the specific Review of Systems data that was captured. If you do not have security permission to edit or add to observations, then you will not be able to.

From the section’s collapsed summary view, simply click on the values/data of the specific Review of Systems line item to edit on or add to. The data will be displayed in a border box where you can begin modifying or typing in more information.

Also while the encounter section is in summary collapsed view, icon options next to the stored data will display.

Trash Can icon: will immediately delete the stored data for the ROS line item. ROS data stores as observations. If you do not have security permission to delete observations, the trashcan icon will still display, but upon click, the system will not allow the data to be deleted.

Eyeball icon: will pop-up the View Observation window to view more specific details of the specific ROS data. Revisions, trending, and entry information will be seen. ROS data stores as observations.

Expanded Encounter Section

Review of Systems data can also be edited on, added to, or cleared/deleted from the expanded encounter summary section. Once Review of Systems data has been documented, the encounter section can be expanded open by clicking anywhere on the grey title section bar. Then, the data can be clicked to edit & add to, or can click X to clear the data out of the field. If you do not have security permission to edit or delete observations, the system will not allow you to modify.

Encounter Stored Document

The Review of Systems encounter section does become part of the encounter visit note document once closed and archived.