What is true about ROS when documenting HPI?

• A. At least one positive symptom must be documented
• B. ROS is optional
• C. HPI must be completely separate from ROS
• D. ROS must be completed with at least one element from past medical or past surgical history and at least one from family or social history

Answer: (A)

In documenting the HPI, the ROS should reflect a real sweep of symptoms across body systems, and many standard practices require that you include at least one positive symptom in that ROS. This shows that you conducted a true symptom review rather than leaving the ROS blank or merely listing negatives. ROS is a defined part of the charting process and is not optional; it complements the HPI by documenting both positive and negative findings across systems. The HPI and ROS are related but not kept completely separate—the HPI describes the current presentation while the ROS systematically records symptoms the patient is experiencing or denies. Past medical history, past surgical history, and family or social history belong in their own sections and are not a requirement to be included as elements within the ROS.