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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

Jason King jr

Mar 28, 2025 — 1 min read

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):

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