I Hate the ROS

Is the Review of Systems Just Too Much Information?

Ranit Mishori, MD, MHS


July 02, 2019

Editorial Collaboration

Medscape &

I dread seeing that piece of paper waiting for me on the door when I enter an exam room. The checklist that we give our patients asking them to note, by checking a box, whether they are experiencing any symptoms: aches, pains, sleep issues, nausea, weight loss, rashes, hair loss, mental health changes, joint swelling—you name it. It is, of course, the review of systems (ROS).

The intention is good. We want to be as comprehensive as possible. We want to care about the whole person and not just specific body parts. We recognize that, sometimes, seemingly unrelated complaints may lead us to a correct diagnosis or a better management plan.

But in reality, the ROS is a huge pain in the neck! Invariably, patients check off multiple boxes. Who hasn't had knee pain in the past several months? Maybe a slight cough? An itch? There really can be such a thing as "too much information."

I confess: I've come to hate this document, as well as its sister electronic version. Literally, it's a document that's asking for trouble. Because, of course, everyone experiences multiple aches and itches and twitches and rashes that come and go in the course of living day to day. Most of them, most of the time, do not merit much concern. More to the point, not all of them can be easily addressed in one short primary care visit.

That's why I was delighted to see an opinion piece[1] in the pages of JAMA written by three University of Minnesota clinicians: Marissa A. Hendrickson, MD and Michael B. Pitt, MD, from the department of pediatrics, and Genevieve B. Melton-Meaux, MD, PhD, from the Institute for Health Informatics. The article makes my private rant sound a little more scientific and respectable. Reviewing the research on the ROS's usefulness, the authors found two things:

  • There is not much data on the matter.

  • The data that do exist offer less than a ringing endorsement for the tool.

Hendrickson and colleagues contend that the ROS does a poor job of identifying new diagnoses and "virtually no data exist about the effect of obtaining a detailed ROS on long-term patient outcomes." Additionally, some studies found that clinicians don't necessarily address everything on the ROS during a patient's visit. One study, conducted in an emergency setting, concluded that only 29% of checked items were addressed.[2] That's not a surprise to me (or to any of my colleagues), given our serious time constraints during a typical day in an outpatient family medicine clinic.

With electronic health records (EHRs) the norm, we now have other means of collecting this data. The nurses, medical assistants, and patients themselves sometimes take on the task of completing forms and questionnaires that ask the myriad questions included in a thorough ROS. And that happens with little guarantee that physicians will actually review it and act on any of the positives.

The workarounds many of us have found (eg, using quick texts and preprepared templates) may also be problematic, because they may not correlate with what was actually reviewed with the patient. Discussing the various issues that come up with recording the ROS in the EHR, the authors noted: "It is not yet clear how clinicians can best take note of and act on ROS findings gathered electronically."

But the issue goes beyond electronic data gathering. The main concern, of course, is not so much how this data collection is done but why it is done in the first place.

The ROS is not about the evidence or best practices but more about Centers for Medicare & Medicaid Services (CMS) rules and regulations around documentation and billing. We have had it drilled into us that we must document a ROS (and I am not talking about pertinent positives/negatives to support a differential diagnosis) so that we can bill at the highest appropriate level. CMS even came up with a somewhat random number of "systems" or elements that we have to review by history or by visit type.

Lamenting "the lack of clear evidence supporting the utility of the ROS in many settings," the authors suggest that "spending time on other activities, such as history taking, or discussion of treatment options, may be more beneficial and clinically appropriate than focusing on the ROS."

I completely agree. Yes, there are bigger fish to fry, but let's recognize that the ROS is a symptom of our broken healthcare system—a low-yield activity that is primarily required for billing and reimbursement purposes. It is not patient-centered and introduces inefficiencies. The collection of this data mirrors an inefficient, non–user-friendly EHR that, similarly, is not clinician- or patient-centered and is inefficient, ineffective, and focused on billing. Hendrickson and her colleagues should be congratulated for getting this issue discussed on the pages of JAMA.

Realistically, I know that the ROS is not going away anytime soon. Until we are granted greater discretion on when to collect this information (based on variables like type of visit, patient characteristics, and practice setting), I know what I will continue to do about it each time I get a new one in my hand. I will review the checked boxes and acknowledge to my patients that I have done so. But then I will seek their cooperation with a simple goal, which I put to them this way: "Unless any of these symptoms is worsening or urgent, let's discuss some of these at your next visit and focus on the main reason you are here today."

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