• See Also
  1. Encounter History
  2. E/M History Criteria
  3. Medical Documentation
  • Approach
  1. Review of Systems includes 14 systems (per CMS)
  • History
  • Constitutional
  1. Fevers
  2. Chills
  3. Night Sweats
  4. Weight loss
  5. Weight gain
  6. Change in appetite
  7. Fatigue
  8. Somnolence
  • History
  • Eyes
  1. Vision Loss or Blurred Vision
  2. Double Vision (Diplopia)
  3. Eye Pain
  4. Red Eye
  • History
  • Ears, nose, mouth, throat
  1. Ear Pain (Otalgia)
  2. Ear discharge (Otorrhea)
  3. Hearing Loss
  4. Ear Ringing (Tinnitus)
  5. Nasal bleeding (Epistaxis)
  6. Nasal Discharge (Rhinorrhea) or post-Nasal Discharge
  7. Sinus pressure
  8. Sore Throat
  9. Oral sores (Oral Lesions)
  10. Tooth Pain
  11. Bleeding Gums (Gingival Hemorrhage)
  12. Hoarse voice (Laryngitis)
  13. Neck Pain
  • History
  • Cardiovascular
  1. Chest Pain
  2. Palpitations
  3. Leg Swelling (Edema)
  4. Leg Pain with walking (Claudication)
  • History
  • Respiratory
  1. Cough
    1. Productive cough
    2. Hemoptysis
  2. Wheezing
  3. Snoring
  4. Shortness of Breath
    1. Shortness of Breath with activity (Dyspnea on exertion)
    2. Shortness of Breath while lying flat (Orthopnea)
    3. Awakening with severe Shortness of Breath (paroxysmal nocturnal Dyspnea)
  • History
  • Gastrointestinal
  1. Nausea or Vomiting
  2. Diarrhea
  3. Constipation
  4. Abdominal Pain
  5. Bright red stools (Hematochezia)
  6. Black tarry stools (melana)
  7. Stool Incontinence (Encopresis)
  • History
  • Genitourinary
  1. Pelvic Pain
  2. Burning with urination (Dysuria)
  3. Frequent Urination (Urinary Frequency)
  4. Urgent urination (urinary urgency)
  5. Blood in urine (Hematuria)
  6. Incomplete Bladder emptying
  7. Urinary Incontinence
  8. Sexually Transmitted Disease Exposure (STD exposure)
  9. Men
    1. Testicular Pain
    2. Swelling in the Scrotum (Scrotal Mass)
    3. Difficulty obtaining or maintaining an Erection (Erectile Dysfunction)
  10. Women
    1. Last Menstrual Period
    2. Heavy Menstrual Bleeding (Menorrhagia)
    3. Missed periods or irregular Menstrual Bleeding (Metrorrhagia)
    4. Vaginal Bleeding after Menopause (Postmenopausal Bleeding)
    5. Menstrual Pain (Dysmenorrhea)
    6. Vaginal Discharge
  • History
  • Musculoskeletal
  1. Bone pain
  2. Joint Pain or Joint Swelling
  3. Muscle pain
  • History
  • Skin (integument, includes Breast)
  1. New rashes or moles or non-healing sores (skin lesions)
  2. Skin itch (Pruritus)
  3. Breast Lumps
  4. Breast Pain (Mastalgia)
  5. Nipple Discharge (Galactorrhea)
  6. Hair Loss (Alopecia)
  • History
  • Neurologic
  1. Headache
  2. Muscle Weakness
  3. Sensation changes such as numbness, coldness, crawling or prickling (Paresthesias)
  4. Memory Loss
  5. Seizure
  6. Dizziness
    1. Light Headedness
    2. Room spinning (Vertigo)
    3. Fainting (Syncope)
    4. Imbalance (Ataxia)
  • History
  • Psychiatric
  1. Anxiety
  2. Sadness
  3. Irritability
  4. Insomnia
  5. Suicidality
  • History
  • Endocrine
  1. Heat intolerance or cold intolerance
  2. Excessive thirst (polydipsia)
  3. Excessive hunger (polyphagia)
  • History
  • Hematologic or Lymphatic
  1. Lymph Node enlargement (Lymphadenopathy)
  2. Easy bleeding or Bruising (Bleeding Disorder)
  • History
  • Allergic or immunologic
  1. Hives (Urticaria)
  2. Seasonal allergies or environmental allergies
  3. HIV Exposure