Demographic Data

Demographic Data 

Age, and gender (must be HIPAA compliant) 

Subjective 

Chief Complaint (CC): A short statement about why they are there 

History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym 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 

• Family Hx: any history of CA, DM, HTN, MI, CVA?  

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- Highlight abnormal findings 
• Assessment (the diagnosis) 

At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each 

• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation 
• Plan 
• Dx Plan (lab, x-ray) 
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any) 

Pt. Education, including specific medication teaching points 

Referral/Follow-up 

Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due 

Reference 

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly. 

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