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Dynamic Review of Systems

About this Command

An important part of a thorough history and critical for appropriate billing, documentation of a complete "Review of Systems" is often laborious and time consuming. Although inserting a "boilerplate" ROS is one solution, this comes with problems, formost among them the potential for stating symptoms about which you did not specifically inquire. Sweeping statements such as "GI: negative, Endocrine: negative" may not pass muster with billing authorities. Likewise, boilerplate ROS listing a thousand symptoms not present leads to the need to make significant alterations to coincide with what was truly questioned and what symptoms you illicited on history. Is there a way to use Dragon to help with this problem?

Review of System Commands:

My method of dealing with a review of systems is to insert a reasonably thorough system-by-system ROS (reflecting those symptoms about which I typically inquire) to be used in conjunction with a command that quickly deletes any symptoms that require modification. Modification may be necessary either because an inquiry was not made or because a positive response was illicited regarding the symptom.

Here's the basic ROS which is contained within a single-cell table and which can either be included in a note template or inserted with the command "Review of Systems" or "Insert Review of Systems":

Once present or inserted, the ROS table is modified as necessary with the command called "Delete <ROS>" in which you simply state "Delete" plus the symptom you want deleted. This can include single word symptoms, i.e. "Delete Confusion" or multi-word symptoms such as "Delete Suicidal Ideation". Each time the command is issued, it deletes the described word and inserts the cursor on the end of the same line so the actual symptom can be described as a positive finding if you like. This is not a highly complex command and simply involves a quick "Find", delete, and movement to the end of the line. In my practice, at least, it has been a time saver and allows inclusion of an honest, accurate ROS into clinical notes, without being time consuming.

The Script:

The script is a simple DVC command with the following programming:

sendkeys "{ctrl+f}"
sendkeys _arg1
sendkeys ", "
sendkeys "{enter}{esc}"
sendkeys "{del}"
sendkeys "{end}"

The problem with this method is the need to remove both the symptom name and subsequent comma. If the command did not remove the comma it would potentially leave a few commas in the text which wouldn't look great. By removing the comma, however, it is essential that every symptom be followed by a comma, lest it not be found with the "find" command. It is for this reason that I threw in the "reported." at the end of each line, so I wouldn't leave an unmodified line ending with a comma. Maybe someone out there can find a better way to do this?

Modification of the Review of Systems Command:

You can easily tailor this command to your own practice by adding or deleting specific symptoms from the table. Here are some suggestions in this regard:

1. If there are specific symptoms or categories of symptoms that you do typically inquire about and which are not listed in the above command, by all means add them to the command (see below for hints on doing this)

2. Unless you are a cardiologist (who like me typically deals with all cardiac-related symptoms in the HPI) you will likely want to remove the "Reviewed above in HPI" statement add pre-defined symptoms to the "Cardiac" category in the command, i.e. (No chest pain, palpitations, orthopnea, PND, edema, syncope or presyncope)

3. If you add any symptom categories or specifically if you add any new symptoms to the list, you will also need to add these to the <ROS> list contained within the "Delete <ROS>" command. This is accomplished by opening the command with the Command Browser, navigating to the appropriate command and attempting to type over the command name. This will cause the MyCommands Name editor to appear, at which time you can highlight the list name "ros" and click edit. From here you can add any new symptoms to the list. As of this time the list contains the following admitedly limited list of symptoms:

abdominal pain
anorexia
anxiety
ataxia
bleeding
change in bowel habits
cold spells
confusion
cough
depression
double vision
drainage
dry eyes
dry mouth
dry skin
dysuria
eye pain
fatigue
fever
focal weakness
frequency
headache
hemoptysis
hot spells
insomnia
joint pain
joint swelling
limb pain
melena
nausea
nocturia
rashes
shortness of breath
sore throat
suicidal ideation
swelling
swollen glands
urethral discharge
visual loss
vomiting
weight loss

Download the Command:

This command set, which includes three commands (Review of Systems, Insert Review of Systems, and Delete <ROS>) can be downloaded as a single Dragon .dat command by clicking on the following link: Download Command. The command set must then be inserted into your own copy of NaturallySpeaking via the command browser. Briefly, this involves opening the Command Browser, clicking on Manage and then Import. Navigate to wherever you have saved the .dat file and you're there!

Good luck using this command. Please pass along any suggestions for improvement.