Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives: SUBJECTIVE CC:

 

Patient Initials:

 

Pt. Encounter Number:

 

Date:

 

Age:

 

Sex:

 

Allergies: Advanced Directives:

 

SUBJECTIVE

 

CC:

 

HPI: Describe the course of the patient’s illness:

 

Onset:

 

Location:

 

Duration:

 

Characteristics:

 

Aggravating Factors:

 

Relieving Factors:

 

Treatment:

 

Current Medications:

 

PMH

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas:

 

Screening Hx/Immunizations Hx:

 

Hospitalizations/Surgeries:

 

Family History:

 

Social History:

 

ROS

 

General

 

Cardiovascular

 

Skin

 

Respiratory

 

Eyes

 

Gastrointestinal

 

Ears

 

Genitourinary/Gynecological

 

SOAP NOTE

 

Nose/Mouth/Throat

 

Musculoskeletal

 

Breast

 

Neurological

 

Heme/Lymph/Endo

 

Psychiatric

 

OBJECTIVE

 

Weight BMI

 

Temp

 

BP

 

Height

 

Pulse

 

Resp

 

PHYSICAL EXAMINATION

 

General Appearance

 

Skin

 

HEENT

 

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Breast

 

Genitourinary

 

Musculoskeletal

 

Neurological

 

Psychiatric

 

Lab Tests

 

Special Tests

 

Diagnosis

 

· Primary Diagnosis-

 

 Evidence for primary diagnosis should be documented in your Subjective and

 

Objective exams.

 

o Differential Diagnoses – Include three diagnoses

 

PLAN including education

 

o Plan:

 

 Further testing

 

 Medication

 

 Education

 

 Non-medication treatments

 

· Referrals

 

 Follow-up visits

 

References