Demographic Data
- Age, and gender (must be HIPAA compliant) Subjective
- Chief Complaint (CC) unless an Annual Physical Exam (APE)
- History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
- Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
- Family Hx: As applicable
- Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
- Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
- Vital signs
- Physical findings listed by body systems, not paragraph form Assessment (Diagnosis/ICD10 Code)
- Include all diagnoses that apply for this visit Plan
- Dx Plan (lab, x-ray)
- Tx Plan: (meds)
- Pt. Education, including specific medication teaching points
- Referral/Follow-up
- Health maintenance (including when screenings, immunizations, etc., are next due):