Medical Specialty:
Office Notes
Sample Name: Normal ROS Template - 3
Description: Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.
(Medical Transcription Sample Report)
HEENT: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.
RESPIRATORY: No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.
CARDIOVASCULAR: No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.
GASTROINTESTINAL: No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.
GENITOURINARY: No dysuria, hematuria, frequency, incontinence or colic.
NERVOUS SYSTEM: No gait problems, strokes, numbness or muscle weakness.
PSYCHIATRIC: No history of emotional lability, depression or sleep disturbances.
ONCOLOGIC: No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.
ALLERGIC/LYMPH: No history of systemic allergy, abnormal lymph nodes or swelling.
MUSCULOSKELETAL: No fractures, motor weakness, arthritis or other joint pains.
Keywords: office notes, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,
