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):
