Demographic Data

• Patient initial (one initial only), age, and gender must be HIPAA compliant. Subjective • Chief Complaint (CC) • 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, iImmunizations , and preventative health maintenance • Family Hx • 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 • Physical findings listed by body systems, not paragraph form Assessment (the diagnosis) • Three (3) differential diagnosis (if applicable) with rationale • Final diagnosis with rationale and pathophysiological explanation 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): Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.