Review of Systems Medical Transcription Phrases and Words For MTs
WORDS & PHRASES COMMONLY DICTATED UNDER THE FOLLOWING SECTIONS IN ROS:
CONSTITUTIONAL:
had some shaking
negative fever or chills
no fever, generalized weakness or malaise
no pyrexia or chills. No weakness or fatigue.
no significant weight changes
no unexplained weight loss
no weight loss, fever, chills, weakness or fatigue
the patient denies fever, weight loss, night sweats, fatigue or bleeding
the patient is rather clammy, pale-looking
arcus senilis
aural fullness
conjunctivae pink, no scleral icterus
contact lens worn
double vision
ears and nose externally normal
goiter
hard of hearing
Head is normocephalic and atraumatic. Eyes, ears, nose and throat are unremarkable
moist buccal mucosa
mouth has no sores
nasal discharge
negative for false teeth
negative for glaucoma or cataracts
negative for masses, hoarseness or snoring
no bleeding gingivae
no change in hearing
no diplopia or blurred vision
no dysgeusia
no dysphagia, dysphonia.
no earache, sore throat or runny nose
no epistaxis or rhinorrhea.
no eye pain
no glossodynia
no hearing loss
no lid lag, no exophthalmos, no xanthelasma
no mucosal lesions
no mucosal pallor
no otalgia, otorrhea
no photophobia
no postnasal drip
no scleral icterus
no scotomata
no sneezing or congestion
No tenderness or difficulty in swallowing
no thrush
no tinnitus or vertigo
no vision disturbances
no visual loss
no xerostomia
patient has full denture plates
PERRL, EOMI
pharynx normal
sinus congestion
The patient wears corrective glasses for reading
ulcerations in mouth secondary to chemotherapy
visual field deficit
wears dentures
clear to auscultation bilaterally
denies any tuberculosis, pneumonia, asthma, pleurisy, bronchitis or sinusitis
dyspnea on exertion
negative shortness of breath, cough, sputum production
no cough or difficulty breathing
no hemoptysis
no hiccups
no history of pulmonary TB
no pleurisy
no PND or orthopnea
there was good respiratory effort
chest pressure
denies history of heart attack
denies night cramps
denies orthostasis
denies substernal or radiating chest pain
negative chest pain on exertion or palpation
no angina
No chest pain, chest pressure, chest discomfort
no history of valve disease
no palpitations or syncope
no precordial pain
No squeezing, strangling, tightness, heaviness or aching about the chest, neck or axilla
positive/negative for hypertension
bright red blood per rectum
denies abdominal fullness
denies black tarry stools
has GERD
melena
no abdominal pain or blood
no acid reflux, heartburn
no anorexia
no constipation
No constipation, diarrhea, black stools, bright red blood per rectum
no epigastric pain
no GI bleed
no hematemesis
no hematochezia
no hemorrhoids
no melanotic stools
no melenemesis
no nausea, vomiting or diarrhea
no odynophagia
no rectal bleeding
GENITOURINARY SYSTEM:
anuric
burning on urination
denies any CVA or suprapubic tenderness
denies pregnancy
diminished urine output
flank pain
has vaginal bleeding
history of carcinoma of the prostate
LMP is current
microscopic hematuria
no difficulty urinating
no dysuria, polyuria, frequency, urgency, hesitancy
no female discharge
no gross blood in the urine
no hematuria or dysuria
no incontinence of bowel or bladder
no kidney stones in the past
no nocturia
no pyuria
no urinary retention
no urinary tract infections
on hemodialysis
pregnancy, last menstrual period
urinary incontinence
varicocele
Review of Systems Transcribed Examples
MUSCULOSKELETAL SYSTEM:
no focal joint pain or stiffness
no joint swelling
no muscle pains
no muscle, back pain, joint pain or stiffness
no myalgias or arthralgias
no neck pain or back pain
no trauma
change in level of consciousness
denies any seizures, convulsions, unconsciousness, speech difficulty or ataxia.
difficult to perform because of poor patient cooperation
negative/positive for migraines
no change in bowel or bladder control
no confusion
no focal weakness
no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities
no history of TIA, CVA
no lightheadedness or slurred speech
no motor or sensory loss
no paresthesias, fasciculations, seizures or weakness
no strokes or seizures
numbness and tingling, stocking/glove distribution
no delusions
no depression, no loss of interest in normal activity or change in sleep pattern
no disorder of thought or mood
no hallucinations or suicidal ideations
no history of depression or anxiety
no mania
no change in skin, hair, nails
no dermatitis
no evidence of squamous or basal cell CA
no rash or itching
no skin rash or skin lesions
no unusual skin spots
positive for hives
vesicular lesions
negative for thyroid abnormalities
negative/positive for diabetes
no fibroid abnormalities
no heat or cold intolerance, polyuria or polydipsia
no sweating
denies abnormal bleeding
denies bleeding disorder
negative for anemia or blood dyscrasias
no abnormal hemorrhaging
no anemia
no easy bruisability
no easy bruising or bleeding
no history of blood clots
no unusual infections or bleeding
no enlarged nodes
