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):