Week 3 Assignment: Review of Systems (ROS) Documentation Walden University

Week 3 Assignment: Review of Systems (ROS) Documentation Walden University

Week 3 Assignment: Review of Systems (ROS) Documentation Walden University

Assignment Guidelines

Using the guidelines in Bickley, Components of the Health History, pp. 7–12, obtain and document a complete ROS on a friend. Document Pertinent Positives and Negatives while taking the ROS, using the Components of the Health History found under “Present Illness.” Include a description with each positive finding on the elicited ROS. Reference pp. 31–33 in the text; the “Case of Mrs. N” gives an example of this type of write-up to use as a guideline.

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Submission

Submit your assignment and review full grading criteria on the Assignment 3.1: Review of Systems (ROS) Documentation page.

Week 3: Practicing, Sequencing, and Coordinating the Comprehensive Assessment

Welcome to the third week of Advanced Physical Assessment. This week, you will learn how to complete a review of systems, otherwise known as an ROS, and also learn about how critical pertinent positives and negatives can be to your assessment and ultimate treatment of care for your patient. You will learn how to appropriately document and identify abnormalities in your patient. Finally, you will discuss how to identify the seven attributes of the symptom.

Review a list of all items due this week in your course syllabus.

Lesson 1: The Comprehensive Assessment

During this lesson, you will learn how to complete a ROS, learn about pertinent positives and negatives, and learn about documenting abnormalities.

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Learning Outcomes

At the end of this lesson, you will be able to:

• Elicit a complete ROS (review of systems) from a friend or family member.
• Accurately document pertinent positives and negatives.
• Accurately document subjective abnormal data.
• Demonstrate the components of symptom analysis using the “seven attributes of a symptom.”

Before attempting to complete your learning activities for this week, review the following learning materials:

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Learning Materials

Read the following in your Bates’ Guide to Physical Examination and History Taking textbook:

• Chapter 5, “Clinical Reasoning, Assessment, and Plan”
• Chapter 6, “Health Maintenance and Screening”
• Chapter 7, “Evaluating Clinical Evidence”

These readings will help you perform and document a health history and also identify the seven attributes of a symptom.

NUR 600 Week 3 Assignment: Review of Systems (ROS) Documentation Sample

General: He reports mild fever and increased fatigue. Negative for chills or weight changes.

 Skin: Negative for skin-color changes, itchiness, rashes, or bruises

 HEENT: Head: Negative for headaches or head injury. Eyes: Reports itchy eyes. No visual loss, blurred vision, double vision, or yellow sclera. Ears: Reports itchy ears. No ear discharge or hearing loss. Nose: Positive for itchy nose, sneezing, nasal congestion, rhinorrhea, and postnasal drainage. No nasal bleeding.

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Throat: Positive for itchy palate. No sore throat or swallowing difficulties.

Neck: No neck pain or stiffness.

 Respiratory: No cough, sputum production, shortness of breath, or chest pain.

Cardiovascular: Negative for edema, palpitations, chest pain, chest pressure/discomfort, SOB on exertion, or fatigue.

 Gastrointestinal: No nausea, vomiting, epigastric pain, bloating, abdominal pain, diarrhea, constipation, tarry stools, or rectal bleeding.

Urinary: No dysuria, urinary frequency, urgency, blood in the urine, or abnormal urine color.

 Genital: Negative for penile discharge, testicular pain, or scrotal swelling. He denies a history of STIs.

Peripheral vascular: Denies having leg cramps, swelling/tenderness in calves, or a history of varicose veins.

Musculoskeletal: No joint pain, joint stiffness, muscle pain, low back pain, or history of fractures.

Psychiatric: He denies having anxiety, depressive, or psychotic symptoms. He denies having an addiction to alcohol or drug substances. No history of psychiatric admission.

Neurologic: Negative for headache, dizziness, fainting, muscle weakness, constant mood changes, loss of sensation, or tingling sensations.

Hematologic: Negative for bruising or bleeding. No history of anemia or blood transfusion.

Endocrine: Negative for heat/cold intolerance, excessive sweating, thinning hair, polydipsia, polyuria, or polyphagia.