Question

A patient who presents with abdominal pain reports experiencing nausea, but no emesis. She has not had a fever, chills, diarrhea, or urinary symptoms. She also denies any recent illness, constipation, rash, or dizziness. In which section of the EMR would you document this information?

Option 1: Past Medical History
Option 2: Social History
Option 3: Review of Systems (ROS)
Option 4: Chief Complaint

Answer 1

A patient's symptoms, such as nausea and abdominal pain without emesis, should be documented in the Review of Systems (ROS) section of the EMR.

Step-by-step explanation:

The information provided by the patient about her symptoms should be documented in the Review of Systems (ROS) section of the Electronic Medical Record (EMR). The Review of Systems is a comprehensive assessment of the patient's body systems and typically includes the patient's symptoms, such as nausea, abdominal pain, and the absence of emesis (vomiting), fever, chills, diarrhea, constipation, rash, or dizziness. This section is used to gather more detailed information about the patient's current health and any symptoms they may be experiencing that could be relevant to their diagnosis.