When a physician documents a patient's response to symptoms and various body systems, these results are recorded as which of the following?

• A. Review of systems
• B. Plan
• C. Physical examination
• D. Assessment

Answer: (A)

When documenting a patient’s experience of symptoms across different body systems, the clinician records an organized inventory of these reported findings. This collection is the review of systems, a history component that captures what the patient says about symptoms rather than what is observed on exam. It differs from the physical examination, which notes objective findings the clinician observes, from the assessment, which states the clinician’s diagnoses or impressions, and from the plan, which outlines treatment and follow-up. By grouping symptoms like fatigue, chest pain, shortness of breath, or abdominal discomfort under system categories, the ROS provides a consistent way to capture the patient’s reported health status. This makes the review of systems the correct designation.