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Demographic Data Age, and gender (must be HIPAA compliant) Subjective Chief Complaint (CC) unless an Annual Physical Exam (APE) History of P

    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… Read More »Demographic Data Age, and gender (must be HIPAA compliant) Subjective Chief Complaint (CC) unless an Annual Physical Exam (APE) History of P