relevant to the patient’s HPI should be described in the HPI, even if elicited when going over the ROS
with the patient. If presented in the HPI, these facts should not be repeated when describing the ROS.
For example, the discovery that a patient presenting with severe aortic stenosis has had multiple
episodes of syncope belongs in the HPI, not the ROS. In contrast, the ROS may reveal that this patient
snores loudly at night and has excessive daytime somnolence. In general, when presenting the ROS, only
positives findings should be included. The presenter can note that the rest of the ROS was negative
while recognizing that some listeners may request additional detail. Problems identified in the ROS need
to be addressed in the assessment and plan below.
Example (for a patient admitted with a COPD flare): “The ROS was positive for mild headaches in the late
afternoons, which respond to acetaminophen. The patient has not had the Pneumovax. The rest of the
ROS was negative in detail.”
Physical Exam: The degree of detail included in the physical exam varies with the setting, time available,
and the patient’s particular problem. Similar to the rest of the presentation, a more detailed physical
exam may be documented in the medical record than is described verbally. More detail is needed when
the exam findings pertain to the patient’s problem, while less detail may be provided elsewhere. When
time is limited, details may be eliminated from the presentation although speakers may be asked to
elaborate. For example, it may be sufficient to say that the mental status exam was normal when a
patient is admitted for a septic elbow. However, more detail is crucial for patients admitted with an
altered mental status. Physical exams should always be presented in the same order with the general
appearance, followed by vital signs, followed by a top to bottom description. By convention, some parts
of the exam are almost always included (vital signs, heart, lungs, etc.) whereas some parts may be
omitted if irrelevant (e.g., presence or absence of epitrochlear lymph nodes). When presenting patients
at the bedside, self-evident details (e.g., the patient is an elderly man) can be omitted. Findings should
not be interpreted here- just give the facts and save the assessment for the appropriate section to
follow.
Example (a patient admitted to the MICU with a GI bleed): “The patient was a fatigued, worried-
appearing, elderly man, lying in bed. The Temperature was 98.5
O
F, Heart Rate 110 and regular,
Respiratory Rate 22, Blood Pressure 94/55, oxygen saturation 98% on RA. The skin was pale without
rashes. The HEENT exam was notable for conjunctival pallor, an NG tube in the left nares, and dry mucus
membranes. The lips were without telangiectasias. No JVD was visible. There was no cervical or
supraclavicular lymphadenopathy. The heart exam was notable for a regular tachycardia, a II/VI early
systolic murmur without radiation, heard best at the LUSB without gallops or rubs. The lungs were clear
to auscultation and percussion. The abdomen was non-distended with normal active bowel sounds and
was mildly tender in the midepigastrium without rebound or guarding. There was no organomegaly.
Pulses were 2+ throughout except for being 1+ in the dorsalis pedis bilaterally. The extremities were
without clubbing, cyanosis or edema. Two 18 gauge IVs were present, one in each arm bilaterally. The
rectal exam showed normal tone, no masses, and black, grossly heme positive stool. The patient was
alert and oriented to name, place, and year. The remainder of the exam, including a full neurological and
GU exam, was unremarkable.