by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Dec 21st, 2015
By: Rikki Runyon (Apr/22/2009)
Review of Systems
CHECKLIST:
-General-
? Weight loss or gain ? Fatigue ? Fever or chills
? Weakness ? Trouble sleeping
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-Skin-
? Rashes ? Lumps ? Itching
? Dryness ? Color changes ? Hair and nail changes
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-Head-
? Headache ? Head injury
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-Ears-
? Decreased hearing ? Ringing in ears (tinnitus)
? Earache ? Drainage
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-Eyes-
? Vision ? Glasses or contacts
? Pain ? Redness ? Blurry or double vision
? Flashing lights ? Specks ? Glaucoma
? Cataracts ? Last eye exam
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-Nose-
? Stuffiness ? Discharge ? Itching
? Hay fever ? Nosebleeds ? Sinus pain
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-Throat-
? Teeth ? Gums ? Bleeding
? Dentures ? Sore tongue ? Dry mouth
? Sore throat ? Hoarseness ? Thrush
? Non-healing sores ? Last dental exam
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-Neck-
? Lumps ? Swollen glands
? Pain ? Stiffness
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-Breasts-
? Lumps ? Pain ? Discharge
? Self-exams ? Breast-feeding
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-Respiratory-
? Cough (dry or wet, productive) ? Sputum (color and amount)
? Coughing up blood (hemoptysis) ? Shortness of breath (dyspnea)
? Wheezing ? Painful breathing
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-Cardiovascular-
? Chest pain or discomfort ? Tightness ? Palpitations
? Shortness of breath with activity (dyspnea)
? Difficulty breathing lying down (orthopnea) ? Swelling (edema)
? Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal Dyspnea)
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-Gastrointestinal-
? Swallowing difficulties ? Heartburn ? Change in appetite
? Nausea ? Change in bowel habits
? Rectal bleeding ? Constipation ? Diarrhea
?Yellow eyes or skin (jaundice)
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-Urinary-
? Frequency ? Urgency ? Burning or pain
? Blood in urine (hematuria) ? Incontinence
? Change in urinary strengt
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-Genital-
Male-
? Pain with sex ? Hernia ? Penile discharge
? Sores ? Masses or pain
? Erectile dysfunction ? STD’s
Female-
? Pain with sex ? Vaginal dryness ? Hot flashes
? Vaginal discharge ? Itching or rash ? STD’s
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-Vascular-
? Calf pain with walking (Claudication) ? Leg cramping
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-Musculoskeletal-
? Muscle or joint pain ? Stiffness ? Back pain
? Redness of joints ? Swelling of joints ? Trauma
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-Neurologic-
? Dizziness ? Fainting ? Seizures
? Weakness ? Numbness ? Tingling
? Tremor
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-Hematologic-
? Ease of bruising ? Ease of bleeding
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-Endocrine-
? Head or cold intolerance ? Sweating ? Frequent urination (polyuria)
? Thirst (polydypsia) ? Change in appetite (polyphagia)
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-Psychiatric-
? Nervousness ? Depression ? Memory loss
? Stress
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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